LIBRARY OF CONGRESS. 



&ps^. inp^rig'^ :fii, 

Shelf .fe..l3 

UNITED STATES OF AMERICA. 

I 



A MANUAL 

OF THE 

PRACTICE OF MEDICINE. 



DESIGNED FOR THE USE OF 

STTJDEIS^TS Am THE GENERAL PRACTITIONER. 



BY , . 

HEE^RT C. MOIE, M. D. 




NEW YORK : 

J. H. VAIL & COMPANT. 
1884. 




Entered, according to Act of Congress, in the year 1881, 
By henry C. MOIR, M.D., 
in the office of the Librarian of Congress, at "Washington, D. C. 



AMBROSE LOOMIS RAMEY, A.M., M.D., 

ADJUNCT PROFESSOR OP ANATOMY IN THE MEDICAL. DEPARTMENT OF THE UNIVKR- 
SITY OF NEW YORK, 

Tliis work is respectfully dedicated., as a mark of esteem and 
gratitude lor h.is many acts of kindness, hy his 
friend and late student, 



1 



PREFACE TO THE THIRD EDITION. 



In presenting this edition to the profession, I have endeavored 
to keep pace with the standard literature of the day. 

To this work I have added (on page 34) the causes of Hepatic 
Abscess, and (on page 399) a chapter on Chorea. 

H. C. M. 

Union Hill, New Jersey. 



PREFACE TO THE SECOND EDITION^ 



The success with which my exertions have been crowned in 
this little work, has far exceeded any reasonable expectations, and 
it has thereby encouraged me to bring out my second edition. 

During the revision of this edition, I have endeavored to follow, 
as far as possible, all suggestions offered by many friends, thereby 
enabling me to make this work as nearly complete as possible, 
thus enhancing its value, both to the student and the busy prac- 
titioner. 

I have especially to thank the editors of the various medical 
journals, for the favorable manner in which the work has been 
received by them, and for many valuable hints thrown out during 
their remarks. 

The work has been enlarged ; several of the diseases have been 
entirely re-written, and all errors, wherever detected, carefully 
expunged. 



PREFACE. 



In a small work like the present manual, nothing can possibly 
be given which will supply the place of exhaustive treatises. It 
must, of necessity, either presuppose some emdition on the part 
of the reader, or be elementary in character to have any special 
value. 

This volume has been designed chiefly to aid the medical prac- 
titioner and student in refreshing their remembrance of the 
pathology, etiology, symptomatology, differential diagnosis, and 
treatment of the more important diseases. 

By grouping the various causes of the more prominent diagnos- 
tic symptoms which are encountered by the physician, an effort 
has been made to /mpress upon the reader that no diagnosis should 
ever be final without a careful study of each individual symptom ; 
and that, to be accurate and rapid in diagnosis, the causes of each 
and every prominent symptom of disease should be particularly 
memorized and constantly reviewed. 

This volume, as it now appears, comprises the substance of a 
course given by a well-known instructor to his private students 
as a preparation chiefly for competitive examination, and em- 
braces also a careful resume of such standard works as those of 
Niemeyer, Roberts, Loomis, Da Costa, Bristowe, Hartshorne, and 
others. 

To be a skillful diagnostician, as it seems to the author, one should 
first know every disease which can affect any tissue or organ; he 



Vi PREFACE. 

should, furthermore, have at his command the causes in full of 
each and every prominent symptom which the patient may 
present; and, finally, be able, by a thorough famiUarity with the 
symptoms of each disease, to exclude, from the list of causes of 
each symptom, such as are not sustained by other points in the 
history of the patient. 

By such a process of deductive reasoning, diagnosis becomes 
more nearly a positive science than by relying upon ' ' keenness of 
perception," or "inborn intuition," which, although valuable as 
aids, are often worthless when the exigencies of the case demand 
a positiveness of diagnosis. 

The arrangement of this volume is intended, as far as possible, 
to assist the reader to master in succession (1) the general basis on 
which the symptoms of disease are divided; (3) all the diseases 
which may be met with in each of the various organs or tissues; 
(3) the more important symptoms of disease and their etiology; 
and (4) the special points pertaining to the diagnosis and prognosis 
of individual forms of disease. This general plan of arrange- 
ment will be found carried out in the successive chapters of this 
volume, with an approa-ch to completeness. 

The author has appended to this volume a number of reliable 
and valuable prescriptions wliich have been obtained from j)ro- 
,minent medical instructors and members of the prof ession who 
have fully proven their value, so as to afford the reader a pocket- 
memorandum of treatment of all the more important diseases; 
while the full details of the treatment of each disease have been 
incorporated throughout the text. Many points of value as to 
the pathology, etiology, and the diagnostic symptoms have been 
selected from the valuable lectures of the more prominent pro- 
fessors of the United States, while no work of prominence has 
been slighted in the preparation of this book. 



PREFACE. 



vii 



The prescriptions, at the close of the manual, are arranged 
according to their therapeutical uses, in alphabetical order, so as 
to enable the practitioner to turn at once to the disease for which 
he seeks a recipe. 

The use of itahcs, throughout the volume, has been adopted 
to make prominent such symptoms as are of special value in 
diagnosis. 

The scope of the work will be found to be quite extensive, 
notwithstanding its small compass, since condensation has been 
the aim of the author in every page, where brevity did not 
demand any important omission. 



i,', 



TABLE OF OO^TEISTTS. 



PART I. 

PAGE. 

General Introduction 1-6 

Explanatory of the Diagnostic Value' of Rational and 
Physical Symptoms. 

PART II. 

An Enumeration of the Diseased Conjditions of Vari- 
ous Parts of the Body {Classified to Aid Memory), 7-16 

PART III. 

Prominent Symptoms of Disease Possessing a Special 

Diagnostic Value, and their Causes 17-34 

Varieties of Pulse. — Causes of Epigastric Pulsation. — 
Causes of Displaced Apex-beat of the Heart. — Causes 
of Abdominal Pain. — Causes of Pain in the Thorax. — 
Causes of Vomiting. — Causes of Headache. — Causes 
of Chill — Causes of Dyspnoea.— Causes of Jaundice. 
— Causes of Coma. — Causes of Ascites.— Causes of 
Hemorrhage from the Digestive Tract.— Causes of 
Haemoptysis. — Causes of Aphonia. — Causes of Hemi- 
plegia. — Causes of Paraplegia. — Causes of Suppression 
of Urine. — Causes of Retention of Urine. — Causes of 
Blood in the Urine. — Causes of Pus in the Urine. — 
Causes of Instantaneous Death. — Types of Expector- 
ation. — Types of Diarrhoea. — Causes of Albuminous 
and Chylous Urine. 

PART IV. 

Diseases of the Respiratory Organs 35-100 

Diseases of the Larynx. — Diseases of the Bronchi, — 
Diseases of the Lungs. — Diseases of the Pleura. 



X CONTENTS. 

PART V. 

PAGE. 

Diseases op the Circulatory System 101-149 

Diseases of the Heart. — Diseases of the Pericardium. 

PART VI. 

Diseases of the Digestive Tract 150-224 

Diseases of the Mouth. — Diseases of the Pharynx.— 
Diseases of the (Esophagus. — Diseases of the Stomach. 
— Diseases of the Intestines.— Diseases of the Liver. 

PART VII. 

Diseases of the Brain and Nervous System 225-260 

Diseases of the Meninges of the Brain. — Diseases of 
the Brain-substance. — Diseases of the Vessels of the 
Brain. — Diseases of the Meninges of the Spinal Cord. 
— Diseases of the Spinal Marrow. — Sun Stroke. 

PART VIII. 

Diseases of the Blood 261-358 

Fevers. — Infarction. — Septicaemia. — Pyaemia. — Ery- 
sipelas. — Rheumatism (its various forms). — Diabetes. 
— Purpura. — Scurvy. — Gout. — Diphtheria. 

PART IX. 

Diseases of the Kidneys.., 359-397 

Renal Congestion.— Renal Hemorrhage. — Uraemia. — 
Bright's Disease (its various forms). — Pyelitis. — 
Hydro-nephrosis. — Renal Calculi. — Renal Cancer. — 
Addison's Disease. — Surgical Kidney. 

PART X. 

Prescriptions ; Disinfectants ; Poisons and Antidotes. 398-446 
Arranged Alphabetically, as to their Therapeutical 
Uses, to Assist Reference. 



Index, 



447 



GENERAL mTEODUOTION". 



GENERAL mTRODUCTION. 



Symptoms or Signs of disease comprise " any past or present 
circumstances afforded by the examination of a patient, or of 
matters concerning him, whence a conclusion may be drawn re- 
garding the nature and seat of existing disease." 

Symptoms are usually classed under one of two heads. Rational 
or Physical. 

A Rational Sign of disease implies, by its derivation, one 
which is perceived by the intelligence only. It is, however, 
generally used in a more liberal sense, and may be said to com- 
prise all forms of manifestations of disease of which the patient is 
self-conscious, or which is capable of being perceived by the pa- 
tient, in case it has escaped attention. 

A Physical Sign, on the contrary, is one which, according to 
its derivation, must be perceived by the senses, in contra-distinc- 
tion to the reasoning faculties. It is therefore, as a rule, unper- 
ceived by the patient or friends, and requires a special cultivation 
of touch, sight, or hearing before it can be accurately determined. 

RATIONAL SIGNS OF DISEASE. 

The rational symptoms of disease form the chief means of diag- 
nosis, except in conditions of the respiratory organs, the heart, 
and the blood-vessels. 

Percussion may, however, be of value in other conditions, since 
it assists in mapping out the situation of organs, or the outline of 
tumors; but the rational symptoms are, as a rule, the great and 
often the only guides in diagnosis, excepting in case of the organs 
above mentioned. 

iVmong the more prominent of the innumerable forms of 
rational symptoms of disease may be enumerated (1) variations in 
the pulse an J temperature, (2j pain, in all its forms and situations, 
(3> cough and expectoration, in all its varieties, (4) nausea and 
vomiting, (5) chill, (6) dyspnoea, (7) diarrhoea, (8j jaundice, (^9; 
coma, (10) ascites, (11) hemorrhage from the different organs, (13) 



4 



GENERAL INTRODUCTION. 



aphonia, (13) constipation, (14) paralysis in all its forms, (15) ab- 
normal conditions of urine, and (16) abnormal attitudes and phy- 
siognomy. 

PHYSICAL SIGNS OF DISEASE. 

Physical symptoms are of value in determining, during hfe, the 
anatomical changes taking place in tissues and organs. In order 
to dectect them, the foUowing methods are employed: (1) inspec- 
tion, {2) palpation, (3) percussion, (4) auscultation, (5) mensuration, 
and (6) succussion. 

Inspection reveals the following points of diagnostic value: 
Condition of the surface; abnormalities of outline and contour (if 
present); deformities; abnormal growths, their character and situa- 
tion; abnormal or deficient movement of parts, especially in the 
chest and abdomen; abnormal points of pulsation; abnormal con- 
ditions of vessels; abnormal physiognomy or attitude of some 
special region of the body. 

Palpation (sense of touch) reveals the following points of diag- 
nostic value: Condition of the surface; condition of the deeper 
tissues; outline and character of new growths; abnormaUty of 
movement of parts, as of chest and abdomen, of tumors, the heart 
impulse, etc. ; abnormality of transmitted impulses, as in vocal 
fremitus, cough impulse of hernia, etc. 

Percussion, by the note produced, determines the relative solid- 
ity of parts. Its note varies between that obtained over cavities 
filled with air and having thin, tense walls, called the tympanitic 
percussion note; and that obtained over fluid or solid tumors, 
where all air is excluded, called flat percussion. The percussion 
note is sometimes also modified bj^ the force of the percussion 
stroke, since the flat note of solid structures is often masked by 
the presence of confined air between the solid body and the sur- 
face. This seldom occurs, however, in the case of fluids. 

Percussion may be performed in one of two ways: directly upon 
the part, called "immediate,'' and indirectly through some inter- 
vening substance, as the finger, etc., called "mediate." In the 
percussion note, as in all forms of sound, the variations are con- 
fined to one of the four elements of soimd, viz., its intensity, 
pitch, duration, and quality. 



GENERAL INTRODUCTION. 



5 



The PITCH modifies both the intensity and duration of all sounds 
as follows: High pitch is accompanied by short duration and 
great intensity. Low pitch is accompanied by long duration and 
diminished intensity. This fact is evidenced in every-day life by 
the intolerance felt towards shrill piercing notes, and the absence 
of such feeling when the pitch is low. 

The intensity may be also increased, irrespective of the pitch, 
by the force of the blow. 

The pitch is modified in disease by the solidity of the underly- 
ing structures; being high or flat when no air is present, and pro- 
portionately lower as the tissues approach the density of air. 

The quality is modified in health by the character of the tissues 
over which percussion is made, and it varies also in certain local- 
ities with the diseased conditions of the parts. The following 
names have been given to percussion sounds as expressive of 
qualities peculiar to certain states of the body. (1) Dullness, if 
over partial consolidation; {2) flatness, if over complete consolida- 
tion or fluid; (3) amphoric, if over air in a small cavity with tense 
walls (this sound may be imitated by blowing into a bottle) ; (4) 
tympanitic if over air in a large cavity with tense walls; (5) vesi- 
culo-tympanitic , as in emphysema; (6) vesicular, the normal per- 
cussion note of lung-tissue; (7) wooden, where a peculiar ring or 
wooden character is present ; (8) cracked-pot, (which requires a 
large superflcial cavity with thin tense walls, communicating with 
a bronchus). Firm percussion should be employed to produce this 
variety of percussion-note, and the patient's mouth should be kept 
open; (9) auscultatory, where a stethoscope is used simultane- 
ously with percussion. 

Auscultation (sense of hearing) admits of the detection of ab- 
normal sounds, which are often of great diagnostic value. These 
sounds vary with different diseases, and are of special value in 
diseases of the lungs, heart, and blood-vessels. 

The prominent auscultatory signs of disease may be thus enum- 
erated: 

Varieties of Respiration. 
Normal or " Vesicular "—is a breezy sound, like the rustling of 
wind through the trees. 



6 



GENERAL INTRODUCTION. 



Rude or " Broncho- vesicular " — is due to partial consolidation 
of lung — is an admixture of tubular and vesicular breathing. 

Tubular or "Bronchial" — is due to complete consolidation of 
lung. 

Exaggerated or " Puerile " — so called since it is normal in child- 
hood—is produced when the lung is doing double duty. 

Amphoric — occurs in cavities with tense walls, opening into a 
bronchus, and near the surface. 

Cavernous — occurs in cavities with flaccid walls, opening into a 
bronchus and near the surface. 

Emphysematous — where the expiratory sound is prolonged and 
of low pitch. 

Phthisical — where the expiratory sound is prolonged and of 
high pitch. 

Cog-ivheel — where the inspiratory sound is jerking and inter- 
rupted. 

Varieties of Rales. 

Dry Rales.— 

Sonorous — due to partial occlusion of a large bronchial tube by 
tumefaction of the mucous membrane, spasm of the mus- 
cular fibre, or mucus. 

Sibilant — due to a similar condition of a small bronchial tube. 
Moist Rales.— 

Crepitant — due to the agglutination of the walls of an air-cell, 
which are subsequently separated by the entrance of air. 

Mucous — due to the flapping of mucus in the bronchial tubes, 
.or the passage of air through mucus, pus, serum, or blood. 

Sub-crepitant — due to fluid or mucus in the ultimate capillaiy 
bronchi. 

Gurgles — due to bubbling of air through fluid in a cavity in 
the lung, where the bronchus is below level of fluid (has 
a peculiar metallic, hollow sound). 
Mucous-click — due to sudden and forcible passage of air through 
a small bronchus, whose sides are brought together by ex- 
ternal pressure or agglutination of their walls. 
Of these rales, all but one are heard ^vith both inspiration and 
expiration, this one exception being the crepitant rale which is 
heard only at the end of inspiration 



AN EirUMEEATIOllfl" OF THE YAEI- 
OUS DISEASED OONDITIOJSTS 
OF THE DIFFEEElsTT PAETS 
OF THE BODY. 



DISEASED CONDITIONS OF THE BODY. 



DISEASES OF THE NERVOUS SYSTEM. 
Diseases within the Cranial Cavity. 
Inflammatory Conditions. 

Acute meningitis. — Subacute meningitis. — Chronic menin- 
gitis. — Acute tubercular meningitis. — Chronic tubercular 
meningitis. — Cerebro-spinal meningitis, epidemic and sporadic. 
— Pachymeningitis, externa and interna. 
Tumors. 

Carcinoma. — Cholesteatoma. — Cysts. — Glioma (exists in nerve- 
tissue). — Gummata. — Hydatids. — Lipoma. — Myxoma. — Psam- 
mom a. — Sarcoma. — Tubercle. 

Conditions of Brain Substance. 

Abscess. — Atrophy. — Cerebral concussion. — Hypertrophy. — 
Sclerosis. — Red softening. — White softening. — Yellow soften- 
ing. — Tumors, as above (except glioma). 

Conditions of Vessels. 

Anaemia. — Apoplexy, cerebral. — Apoplexy, meningeal. — 
Atheroma. — Embolism. —Fatty degeneration. — Hyperaemia, 
active. — Hypersemia, passive. — Miliary aneurism. — Throm- 
bosis. 

Diseases within the Spinal Cord. 

Inflammatory Conditions. 

Cerebro-spinal meningitis. — Diffuse idiopathic spinal menin- 
gitis. — Localized idiopathic spinal meningitis. — Traumatic 
spinal meningitis. 

Tumors of the Spinal Meninges. 

Carcinoma.— Cysts. — Enchondroma. — Gummata. — Hydatids. 
—Lipoma. —Myxoma. —Sarcoma. —Spina bifida. —Tubercle. 

Conditions of the Spinal Marrow. 

Abscess. — Concussion. — Locomotor ataxia. — Sclerosis. — 



10 AN ENUMERATION OP THE VARIOUS DISEASED CONDITIONS 

White softening.— Red softening or myelitis. — Tumors (as 
above, excepting Spina bifida). 
Conditions of Vessels. 

Active hypersemia. — Passive hyperaemia or "congestion." — 
Anaemia. — Apoplexy, meningeal or spinal. — Atheroma. — 
Embolism. - Fatty degeneration. — Thrombosis. 

ORGANS OF DIGESTION. 
Diseases of the Buccal Cavity. 

Inflammatory Conditions. 

Simple or catarrhal stomatitis. — Mercurial stomatitis. — Croup 
ous stomatitis.— Aphthous sore mouth.— Diphtheritic stom 
atitis. — Cancrum oris. — Exudative stomatitis. — Thrus\ 
or " sprue." — Gangrenous stomatitis. — Noma or "watei 
canker." 

Mucous patches (syphilitic). 

Ulcers (non-specific). 

Parotitis or "mumps." 

Glossitis. , 
Scorbutic condition. 
Lead affections. 
Gummata of tongue. 
Surgical Diseases. 

Epithelioma.— Tumors of bone. — Necrosis. — Caries. — EpuHs. 

— ParuKs.— Ranula. — Cleft-palate. — Hare-lip. 
Eruptions of the different fevers. 
Angina Ludovici. 

Diseases of the Pharynx. 

Inflammatory Conditions. 

Catarrhal pharyngitis. — Croupous pharyngitis.— Follicular 
pharyngitis. — Diphtheritic pharyngitis. — Phlegmonous 
pharyngitis.— Retro-pharyngeal abscess.— Gangrene. —Angina 
Ludovici. —Ulcers. 

Syphilitic Conditions. 

Specific catarrh.— Specific ulcers.— Mucous papules.— Condy- 
lomata. — Gummata. — Cicatrices.— Constrictions and distor- 
tions of pharynx, froui adhesions or cicatrizations. 



OF DIFFERENT PARTS OF THE BODY. 



11 



Cancer of the pharynx. 

Polypi of the pharynx. 

Diseases of the GEsophagus. 

Inflammatory Conditions. 

Catarrhal oesophagitis. — Croupous oesophagitis. — Diphtheritic 
oesophagitis. — Pustulee (small-pox). — Ulcers, as in chronic 
catarrh. — Ulcers from corrosive substances. — Ulcers from 
foreign bodies. 

Stricture as a result of 

Cicatrices.— Compression (from outside sources). — Hyper- 
trophy of its walls. — New growths in the oesophagus. 

Dilatation of the (Esophagus. 

Partial dilatation, if circumscribed. — Total dilatation if affect- . 
ing the entire length. 

New Growths. 

Carcinoma. — Fibroid tumors. — Gummata (rare). — Tubercle 
(rare). 

Perforation or Rupture. 

From abscess of bronchial glands. — From aneurism. — From 
cancer. — From caries of the vertebrae. — From corrosion.— 
From ulcers. 

Nervous Conditions. 

Globus hystericus (spasm). — Hyperaesthesia. — Paralysis. 
Diseases of the Stomach. 

Inflammatory Conditions. 

Acute catarrhal gastritis. — Chronic catarrhal gastritis. — Sub- 
acute catarrhal gastritis. — Croupous gastritis. — Diphtheritic 
gastritis. — Phlegmonous gastritis. —Toxic gastritis.— Ulcers, 
acute or perforating, and chronic. — Cancer, scirrhus, medul- 
lary, and colloid. 

Nervous Conditions. 

Dyspepsia. — Spasm or " gastralgia." 

Unclassified Conditions. 

Dilatation of the stomach. — Rupture of the stomach. — Stric- 
ture of the stomach. 

Hemorrhage dependent upon 

Ulcer. — Cancer. — Thrombosis of portal vein. — Cirrhosis of the 



V 



12 AN ENUMERATION OF THE VARIOUS DISEASED CONDITIONS 



liver. — ^Acute yellow atrophy of the liver. — Enlargement of 

gall-ducts. — Pulmonary obstruction. — Tricuspid regurgitation. 

— Hemorrhagic diathesis. — Rupture of aneurism and varices. 

— Traumatism. — Improper living (as abstinence from meat or 

vegetables). 
Blood Conditions. 

Yellow fever. — Malaria. — Scurvy. — Purpura . 
Ulcers. 

Acute or perforating. — Chronic catarrhal. — Phlegmonous. — 
Scrofulous. — SyphiKtic. — Diphtheritic. — Cancerous. — Vario- 
lous. — Corrosive (due to poisons). — Typhus. — Typhoid, — Fol- 
licular. 

Diseases op the Intestinal Canal. 

Inflammatory Conditions. 

Acute and chronic catarrhal enteritis. — Gastro-duodenitis 
(cholera morbus). — Perforating duodenal ulcers (as occur in 
burns). — Peri-typhlitis. —Proctitis and peri-proctitis. — Typhoid 
conditions. — Dysentery, sporadic and epidemic. — Cholera 
morbus. — Asiatic cholera. 

Tumors. 

Vascular. — Carcinoma. — Tubercle. — Fatty tumors (lipoma). — 
Scrofulous enlargements of the mesenteric glands. 

Conditions Dependent upon the Vessels. 

Intestinal hemorrhage. — Vascular dilatations. 

Conditions impairing the free action of the Boivels. 

Contractures, by adhesions or bands of lymph. — Rupture or 
perforation. — Foreign bodies — Volvulus. — GaU-stones. — Intus- 
susception. — Peritoneal bands. — Hernia. — Worms. — Strangu- 
lation. — Pressure of tumors and cancer. — Impaction of faeces. 

Unclassified Conditions. 

Worms. — Tympanites or wind colic. — Intestinal coUc. — Lead 
colic. 

Diseases of the Liver. 
Inflammatory Conditions. 

Affecting the capsule of the organ (peri-hepatitis). — Affecting 
the parenchyma of the liver (diffuse hepatitis).— Affecting the 
connective tissue (cirrhosis).— Circumscribed suppm-ative in- 
flammation (abscess). — Ascites.— Jaundice. 



OP DIFFERENT PARTS OF THE BODY. 



13 



Degenerations. 

Amyloid or waxy liver. — Fatty liver. — Acute yellow atrophy, 

— Chronic atrophy from pressure. 
Abnormal Conditions of the Vessels. 

Active hyperaemia. — Passive hypersemia (nutmeg liver). — 

Hepatic apoplexy. — Hepatic infarction. — Portal thrombosis. 

— Suppurative portal phlebitis. — Embolism of hepatic artery. 
Hepatic Tumors. 

Cancerous tumor. — Tubercle. — Cysts, simple and hydatid. — 

Carcinoma. — Gummata. — Enlarged gall-bladder. 
Conditions of Bile Ducts. 

Gall-stones. — Catarrhal obstruction. — Croupous obstruction. 

— Foreign bodies in the duct. — Tubercle,— Cancer. 

ORGANS OF RESPIRATION. 

Diseases op the Larynx. 

Inflammatory Conditions. 

Acute catarrhal laryngitis. — Chronic catarrhal laryngitis. — 
Croupous catarrhal laryngitis. — Diphtheritic laryngitis. — 
Tuberculous laryngitis. — Syphilitic laryngitis. — Laryngeal 
peri-chondritis. — (Edema glottidis. 

Ulcers. 

Catarrhal. — Typhus. — Variolus. — Syphilitic . — Tubercular. 

New Growths. 

Papillary or warty. — Mucous polypi. — Fibrous tumors. — Car- 
cinoma.— Cystic tumors. 

Nervous Conditions. 

Laryngeal spasm (false croup). — Paralysis of muscles of larynx. 
Diseases op the Bronchi. 

Inflammatory Conditions. 

Acute catarrhal bronchitis. — Chronic catarrhal bronchitis. — 
Capillary catarrhal bronchitis. — Croupous bronchitis. — Diph- 
theritic bronchitis. — Bronchial dilatation. 

Nervous Conditions. 

Asthma. — Whooping cough. 

Surgical Conditions. 

Foreign bodies. — Occlusion by pressure, or from tumors. 



14 AN ENUMERATION OF THE VARIOUS DISEASED CONDITIONS 



Diseases of the Lungs. 

Inflammatory Conditions. 

Croupous or lobar pneumonia. — Catarrhal or lobular pneu- 
monia. — Chronic, or interstitial pneumonia. — Pulmonary ab- 
scess. — * Pulmonary gangrene. — * Pulmonary oedema. 

Conditions dependent upon the vessels of the Lung. 

Pulmonary apoplexy. — Pulmonary infarction. — Pulmonary 
oedema. — Pulmonary gangrene. — Active hyperasmia. — Passive 
hypersemia. — Compensatory liypergemia. — Brown induration. 
— Splenization. —Hypostatic congestion . 

Conditions dependent upon an altered state of the Air-cells. 

Collapse (atelectasis). — Emphysema, vesicular. — Emphysema, 
interlobular. — Phthisis, catarrhal. — Phthisis, tubercular.— 
Phthisis, fibrous. — Compression of the lung. 

Cancer of the lung. 

Diseases of the Pleura. 

Inflammatory Conditions. 

Acute pleurisy. — Subacute pleurisy. — Chronic pleurisy (empy- 
ema). — Traumatic pleurisy. 

Pneumo-thorax. 

Hydro-thorax (non-inflammatory). 

Haemo-thorax. 

Hydro-pneumo -thorax. 

Cancer of the pleura. 

Tubercle of the pleura. 

Adhesions of the pleura (usually secondary to an inflammatory 
process). 

Diseases of the Heart and Pericardium. 

Inflammatory Conditions. 

Acute endocarditis.— Chronic endocarditis.— Ulcerative endo- 
carditis.— Myocarditis. —Pericarditis, with serous effusion. — 
Pericarditis, with pus exudation. — Pericardial adhesion. 

Abnormal Valvular Conditions. 

Aortic obstruction. — Aortic insufficiency. — Pulmonary 



* Pulmonary oedema and gangrene are not always of inflammatory oi-igin ; 
hence enumerated under two headings. 



OF DIFFERENT PARTS OF THE BODY. 



15 



obstruction and insufficiency. — Mitral obstruction and in- 
sufficiency. — Tricuspid obstruction and insufficiency. — 
Vegetations on the valves. — Rupture of chordae tendinese. — 
Hypertrophy, 3 varieties, simple, eccentric, and concentric, — 
Rupture of the heart. 

Unclassified Conditions of the Heart. 

Fatty degeneration of the heart. — Amyloid degeneration of 
the heart. — Angina pectoris. — Cardiac neuralgia. — Heart clot, 
or cardiac thrombosis, — Cardiac polypus. — Cardiac dilatation, 
3 varieties, simple, hypertrophous, and atrophic. 

Conditions of the Pericardium. 

Basedow's disease. — Pneumo-pericardium. — Haemo-pericar- 
dium. — Cancer of pericardium. —Aneurism in pericardial sac. 
— Tubercle of pericardium. 

THE URINARY ORGANS. 
Diseases of the Kidney. 
Inflammatory Conditions. 

Catarrhal or desquamative nephritis. — Croupous nephritis. — 
Chronic parenchymatous nephritis. — Acute interstitial nephri- 
tis. — Chronic interstitial nephritis. — Peri-nephritis. — Amyloid 
degeneration. — Abscess in kidney. — Fatty degeneration. — 
Pyelitis. — Surgical kidney. 
Renal Tumors. 

Carcinoma. — Tuberculosis. — Parasites. — Cysts, due to oblitera- 
tion of kidney tubules. 

Abnormal Conditions of Vessels. 

Active hyperaGmia or congestion. — Passive hypersemia. — In- 
farction . — Thrombosis . — Embolism . 

In the Cavity of the Kidney. 

Hydro-nephrosis or dropsy of kidney. — Calculus in the pelvis 
of the kidney. 

Affecting Supra-renal Capsule. 
Addison's disease. 

Diseases of the Bladder. 

Inflammatory Conditions. 

Acute catarrhal cystitis. — Chronic catarrhal cystitis. — Ulcer- 



16 AN ENUMERATION OF THE VARIOUS DISEASED CONDITIONS. 



ation. — * Paralysis. — Croupous cystitis. — Diphtheritic cys- 
titis. 
Tumors. 

Cancer. — Tuberculous. — Vegetations. 

Nervous Conditions. 

Atony. — Spasm . — Paralysis. — Neuralgia. 
Conditions affecting the cavity of the Organ. 

Dilatation. — Rupture. — Retention. — Incontinence. — Overflow. 

— Calculus in the bladder. — Hemorrhage. 

A CLASSIFICATION OF THE ABNORMAL STATES OF THE 

BLOOD. 

Changes in its Corpuscular Elements. 

Increase of red globules (plethora). — Increase of white globules 
(leucocythemia,\ — Decrease of red globules (anaemia). — De- 
crease of red and white globules (chlorosis). — Disorganization 
of globules (fevers). 

Changes in its Inorganic Elements. 

Increase in chloride salts. — Increase in alkaline salts (some 
nervous diseases). — Decrease in chloride salts. — Decrease in 
alkaline salts (scurvy). 

Changes in its Organic Elements. 

Incresase in fibrin (starvation, inflammation). — Increase in 
albumen (inflammation). — Decrease in fibrin (all the fevers). — 
Decrease in albumen (all the fevers). — Increase in fat (chylse- 
mia). — Decrease in fat (tuberculosis) (?). 

Changes Dependent upon Mal-assimilation. 

Excess of lactic acid (rheumatism). — Excess of uric acid 
(gout). — Excess of oxalic acid (oxaluria). — Excess of sugar 
(diabetes). 

Changes due to Poisons Developed icithin the Body. 

Uraemia . —Ammonsemia. — Cholestraemia. — Cyanosis. — Intes- 
tinal secretion (fetid odor to breath). 

Changes due to Poisons Developed outside the Body. 

Glanders. — Anthrax. — Hydrophobia. — Snake-bite. — Syphilis. 
— A 11 the fevers. — Dysentery. — Cholera. — Cerebro-spinal 
meningitis (?). — Pyaemia. — Septacemia. — Fevers. 



* May also be dependent on many otiicr causes. 



PEOMmEE"T SYMPTOMS OF DIS- 
EASE, POSSESSING A SPECIAL 
DIAGNOSTIC IMPORTANCE, 
AND THEIE VALUE. 



PEOMINENT SYMPTOMS OF DISEASE, POSSESS- 
ma A SPECIAL DIAGNOSTIC VALUE. 



VARIETIES OF PULSE. 

Modifications in Volume. 

Ful] pulse. — Small pulse. — Thready pulse. — Gaseous pulse. 

Modifica lions in Rhythm. 

Regular, where the rhythm is perfect. — Irregular, where the 
number of beats per minute or fraction of a minute is not uni- 
form. — Intermitting, where the beats cannot be perceived at 
intervals. — Delayed, where the radial pulse and the apex beat 
are not synchronous with each other. 

Modificctions in Force. 

Weak pulse. — Strong pulse. — Suppressed pulse. — Jerking 
pulse. — Compressible pulse. — Incompressible pulse. — Wiry 
pulse. — Shot pulse (in aortic regurgitation). 

Modificatiojis shown by the Sphygmograph. 

Dicrotic, where the aortic wave is prominent and the aortic 
notch approximates toward the respiratory line. — Fully Di- 
crotic, where the aortic ivave is prominent and the aortic 
notch on a level with the respiratory line. — Hyper-dicrotic, 
where the aortic notch falls below the respiratory line. 
The depth of the aortic notch shows the tension or emptiness of 

the vessels. The less the depth the greater the tension. The 

greater the depth the greater the em]3tiness of the vessels.* 

CAUSES OF EPIGASTRIC PULSATION. 

Aneurism of cseliac axis. 
Aneurism of abdominal aorta. 



* A state of great tension after scarlet fever is indicative of a developing kid- 
ney complication. 



30 



PROMINENT SYMPTOMS OF DISEASE 



Tumors lying upon the abdominal aorta. 

Displacement of the heart toward the right side. 

Pulsation in the hepatic veins and inferior vena cava (due to tri- 
cuspid regurgitation). 

Transmission of the heart impulse through the left lobe of the 
liver. 

A relaxed condition of the abdominal aorta, or its loose attach- 
ment to the vertebrae. 

Hypertrophy of right auricle (as in emphysema, tricuspid regurgi- 
tation, etc.). 

CAUSES OF DISPLACEMENT OF APEX BEAT OF HEART. 
Downward. 

Emphysema. — Mediastinal tumors. — Cancer of lung or upper 
part of pericardium. — Cardiac dilatation. — Hypertroph}' of 
right and left ventricles of heart. 
Upward. 

Dilatation of right ventricle of heart (?). — Distended stomach. 
Enlarged left lobe of liver. — Enlarged spleen. — Tympanites. — 
Abdominal tumors (if very large). — Ascites (if extensive). 
Laterally. 

Fluid in pleural cavities. — Pleuritic adhesions. — Pleurisy. — 
Emphysema. — Mediastinal tumors. — Abdominal tumors (if 
the development is most extensive on the right side). 

CAUSES OF ABDOMINAL PAIN. 
Conditions of Stomach. 

Gastritis (all varieties). — Ulcers of stomach.— Cancer of stom- 
ach. —Distention of stomach.— Rupture of stomach.— Gastro- 
dynia. 

Conditions of Intestines. 

Enteritis (all varieties). — Dysentery (all varieties). — Impaction 
of faeces. — Stoppage of bowel, and its causes. — Tympanites. — 
Wind colic. — Lead colic. — Typhoid conditions.— Tuberculous 
ulcers. — Perforation. — Typhlitis. — Peri-typhlitis. — Peri-proc- 
titis.— Cancer. 

Conditions of Liver. 

Hepatic colic (gall-stones). —Cirrhosis. — Hepatitis. — Peri-hepa- 



POSSESSING A SPECIAL DIAGNOSTIC VALUE. 



21 



titis.— Abscess of liver. — Cancer of liver. — Hydatids of liver. 

— Tumors of liver. — Pylo-phlebitis. 
Conditions of Kidney. 

Renal colic (gravel). — Renal abscess. — Pyelitis — Pyo-nephro- 

sis. — Hydatids. — Cancer. — Peri-nephritic abscess. — Addison's 

disease. 
Conditions of Spleen. 

Malarial enlargement. — Leucocythemia (by pressure on other 

organs). 
Conditions of Peritoneum. 

Localized peritonitis. — Tuberculous peritonitis. — Acute peri- 
tonitis.— Cancer of omentum. 
Conditions of Ovary. 

Ovarian tumors. — Prostitutes' colic (ovaritis). 
Conditions of Uterus. 

Metritis. — Endo-metritis. — Cancer. — Rupture. — Polypus. — 

Tubal pregnancy.— Flexions. 
Conditions of Bladder. 

Cystitis (all forms). — Retention of urine. — Rupture of bladder. 

— Spasm of bladder. — Cancer of bladder. — Ulceratioi; of blad- 
der. — Calculus. 
Conditions of Vessels. 

Aneurism. — Hsematocele. 

CAUSES OF PAIN IN THE THORAX. 
Affecting Respiratory Organs. 

In the Lung. 

Bronchitis (acute). —Pneumonia. — Cancer. — Abscccss. — Infarc- 
tion. — Phthisis. — Foreign bodies in bronchi. 
In the Pleura. 

Pleurisy (all varieties). — Pneumo-thorax. — Hsemo-thorax, — 

Cancer. 
Located in Mediastince. 

Mediastinal tumors. — Diaphragmatic hernia. 

Affecting Heart and Coverings. 
In the Heart and Pericardium. 

Pericarditis (all varieties). — Pneumo-pericardlum.— Hsemo- 



32 



PROMINENT SYMPTOMS OF DISEASE 



pericardium. — Cancer of pericardium.— Myocarditis.— Ulcer- 
ative endocarditis. —Angina pectoris. - Cardiac neuralgia. 
Affecting Walls of Thorax. 

Surgical Conditions. 

Contusions. — Traumatisms. — Fracture of ribs. — Fracture of 
vertebrae (dorsal). — Dislocation of vertebrae (dorsal). 

Diseased Conditions. 

Intercostal neuralgia. — Muscular rheumatism.— Abscess in 
soft tissues over the thorax. —Cancer of soft tissues. — Cancer 
of thoracic walls. — Tumors of thoracic walls. — Stricture of 
oesophagus. 

Abdominal Causes. 

Dyspepsia.— Abdominal pressure upward. 

CAUSES OF VOMITING. 
Local. 

Gastritis (all varieties).— Gastric cancer.— Gastric ulcer. — Dyspep- 
sia. — Stricture of stomach. — Cirrhosis of liver (from passive 
hyperasmia of the stomach). — Cholera (from desquamation of 
the epithelium). — Cholera morbus. — Impaction of faeces.— 
Peritonitis. — Strangulated hernia. — Volvu lus. — Intussuscep- 
tion. — Worms in stomach or intestines. — Mechanical irritants 
(as mustard, emetics, poisons, etc.). 

Reflex. 

Diseases of uterus. — Diseases of ovaries. — Diseases of kidney. — 
Diseases of spleen. — Diseases of liver. — Diseases of bladder. — 
Diseases of testicle. — Diseases of brain. — Diseases of spinal 
cord. — Pregnancy. — Irritation of palate or fauces. — Irritation 
of olfactory nerve (by odors).— Severe pain (from any cause). 
Blood. 

Poisons of a Medicinal Nature. 

Emetics. — Narcotics. — Cardiac sedatives. — Anaesthetics. 
Poisons from the Body. 

Uraemia. — Cholaemia.— Ammonaemia. — Uric acid. — Choles- 

traemia. 
Malarial poisoning. 



POSSESSING A SPECIAL DIAGNOSTIC VALUE. 



23 



All the fevers. 
Hemorrhage (if profuse). 
Anaemia. 
Chlorosis. 

CAUSES OF HEADACHE. 
Cranial Causes. 
Anaemia of cerebral capillaries. — Congestion of cerebral capillaries. 

—Thrombosis of cerebral capillaries. — Embolus of cerebral 

capillaries. — Cerebral apoplexy. 
Inflammatory Diseases. 

Meningitis (9 varieties— see page 9). — Cerebritis. — Cerebral 

abscess. — Caries and necrosis. 
Tumors of meninges and of brain substance (see page 9). 
Cerebral concussion. 

Reflex Causes. 

Abnormal states of stomach. — Abnormal states of uterus. — Preg- 
nancy.— Constipation. — Excessive venery. 

Blood Causes. 

Poisons. 

All the fevers. — Malaria. — Diphtheria. — Syphilis. — Uraemia. 
— Cholaemia. — Cholestraemia. — Pyaemia. — Septicaemia. — Medi- 
cinal agents. — Alcohol. 

A.naemia. 

Chlorosis. 

Scurvy. 

Purpura. 

CAUSES OF CHILL. 
General Axiom. 
Any disease in which a marked and sudden rise in temperature 
occurs, may be ushered in with or accompanied by a chill. 

1. All inflammatory diseases of any of the various organs or 

structures of the body, if severe, may begin with a chill. 

2. Blood Poisons. 

Pyaemia. — Septicaemia. — Puerperal fever. — Malaria. — All the 
fevers. — Erysipelas. — Surgical fever. 
8. Nervous Causes. 

Sudden shock. — Nervous exhaustion.— Mental emotion. 



24 



PROMINENT SYMPTOMS OF DISEASE 



CAUSES OF DYSPNCEA. 
Is due to some mechanical interference to the free entrance of 

air to the lung. 

Causes aho je the Larynx. 

May result from pressure on facial nerve. — May result from 
obstruction in nares. — Suppurative tonsillitis. — Retro-pharyn- 
geal abscess. — Cancer of mouth or pharynx. — Tumors of 
mouth or pharynx. — Foreign bodies in pharynx. 

Causes in the Larynx. 

Laryngitis (5 forms — see page 13). — CEdema glottidis. — Laryn- 
gismus stridulus. — Laryngeal tumors. — Laryngeal paralysis. — 
Pressure upon the larynx. — Foreign bodies in larynx. 

Causes in Bronchi. 

Bronchitis (its various forms).- -Asthma. — Foreign bodies in 
the bronchi. — Hemorrhage from a bronchus. — Pressure on a 
bronchus. — Bronchial dilatation. 

Conditions of the Lungs. 

Emphysema. — Pneumonia. - Phthisis. — CEdema. — Conges- 
tion. — Infarction. -^Apoplexy. — Abscess. — Cancer. — Gan- 
grene. — Atelectasis. — Compression of the lung. 

Conditions of the Pleura. 

Pleurisy, acute. — Pleurisy, subacute. — ■ Pleurisy, chronic 
(empyema''. — Pleuritic adhesions. — Hydro-thorax. — Pneumo- 
thorax, — Hydro-pneumo-thorax. — Haemo-thorax. — Cancer. 

Conditions of the Heart. 

Pressure on the heart. — Enfeebled heart's action. — Mitral dis- 
ease. — Rupture of valves. — Angina p3ctoris. — Cardiac dilata- 
• tions. — Fatty heart. — Myocarditis. — Endocarditis (ulcerative 
form chiefly). — Greatly accelerated heart's action. 

Conditions of the Pericardium. 

Pericarditis with effusions. — Pericardial adhesions. — Pneumo- 
pericardium. — Hydro-pericardium, — Hsemo-pericardium. — 
Cancer of pericardium.— Pus in pericardium. 

Conditions of the large Vessels. 

Aneurism of arch (by pressure on lung). — Aneurism of peri- 
cardial sac (by pressing on heart). — Air in veins. 



POSSESSING A SPECIAL DIAGNOSTIC VALUE. 



2b 



Conditions of Air Respired. 

Deficiency of oxygen. — Too higli altitudes. — Deleterious sub- 
stances and impurities in the air. 

Conditions of Blood. 

Ansemia. — Chlorosis. — Poisons. 

Conditions of the Nervous System. 

Diseases of the brain. — Diseases of upper part of the spinal cord. 
— Injury to or pressure upon the following nerves : Pneumo- 
gastric, Phrenic, Spinal Accessory, Laryngeal, Cardiac. — Ex- 
haustion. — Tetanus . — Hydrophobia. 

Conditions affecting Parietes or Muscles of Chest. 

Spasm of chest muscles. — All painful affections of structures 
external to chest. — Paralysis of respiratory muscles. — Wounds 
or contusions of soft tissues. — Ossified cartilages. — Fracture 
of ribs. — Dislocation or fracture of spine (in dorsal region). 

Conditions affecting the movements of the Diaphragm. 

Enlarged organs, including pregnancy. — Tympanites. — Asci- 
tes. — Peritonitis (from the pain). — Tumors. 

CAUSES OF JAUNDICE. 
Hepatogenous (Obstructive). 

Affecting the common Bile-duct. 

Congenital defect of the valve in the duct. — Extension of catar- 
rhal inflammation from the intestines. — Plugging of duct by 
calculus. — Plugging of duct by hydatids. — Plugging of duct by 
mucus. — Plugging of duct by foreign bodies. — Plugging of 
duct by worms. — Stricture of the duct. — Pressure on duct by 
abdominal tumors. — Pressure on duct by enlarged lympha- 
tics. 

Affecting the Radicals of the Bile-ducts. 

Cancer of the liver. — Hydatid of the liver. — Abscess of the 
liver. — Cirrhosis of the liver. — Gummata. — Tuberculosis.— 
Hypersemia. — Hyperplastic inflammation of the capsule of 
Glisson, in the transverse fissure of the liver. 

Hematogenous (Non-obstructive). 

Blood Poisons. 

Malaria. — Antimony. — Phosphorous. — Snake bites. — Pygemia. 
— Se.ptacemia. — Aneesthetics. — Fevers. 



26 



PROMINENT SYMPTOMS OP DISEASE 



Emptiness of blood-vessels of the liver (favoring osmosis). 

Hypersecretion of bile. 

Acute yellow atrophy. 

Fevers. 

Pneumonia. 

Mental emotions. 

Secondary to the hepatogenous variety. 

CAUSES OF COMA. 
Cranial Causes. 

By producing Pressure or Injury. 

Bony tumors. — Suppuration, from caries or necrosis. — Depres- 
sed fracture. — Meningitis (9 varieties — see page 9) due to 
pressure from the exudation. — Meningeal hemorrhage. — 
Meningeal tumors (see page 9), — Abscess of brain, — Sclerosis 
of brain. — Apoplexy. — Tumors of the brain (see page 9). 

Affecting the Generative Power of Nerve Centres. 

Cerebral softenings, red, white, and yellow. — Cerebral con- 
cussion. — Cerebral anaemia. — Thrombosis . — Embolism. 

Nervous Causes. 

Epilepsy. — Hysteria. — Catalepsy. — Syncope (through the 
sympathetic). — Reflex coma (especially in children). 

Blood Poisons. 

All the fevers. — Malaria. — Diphtheria. — Urgemia. — Pyaemia. - 
— Septicaemia. — Alcoholism. — Cholestraemia. — Ammonaemia. 
--Narcotics, such as chloral, opium, 'etc. — Cholaemia. — Anaes- 
thetics. 

CAUSES OF ASCITES. 

In the Liver. 

Pressure on portal vein from abdominal tumors. — Atrophy of 
liver. --Cirrhosis of liver (from pressure on portal vein). — Can- 
cer. — Waxy liver. — Enlarged lymphatic glands in transverse 
fissure of the liver. — Hydatids. — Abscess.— Tubercle. — Gum- 
mata. — Portal thrombosis. 
In the Heart. 

Triscupid regurgitation (by causing imperfect venous return 
to the right auricle). 



POSSESSING A SPECIAL DIAGNOSTIC VALUE. 



27 



In the Lungs. 

Emphysema.— Cancer.— Fluid in pleural sacs.— Mediastinal 

tumors (by causing insufficiency of tricuspid valve). 
In the Kidneys. 

Chronic Bright's (by producing a general hydrsemia). 
Peritoneal Causes. 

Cancer of peritoneum. — Tubercular disease of peritoneum.— 

Chronic inflammation of peritoneum. 
Blood Causes. 

Anaemia. — Hydrsemia. — Chlorosis. — Purpura. — Scurvy. 

CAUSES OF HEMORRHAGE FROM THE DIGESTIVE 
TRACT. 

From the Stomach (H^matemesis). 

Dependent on Stomach. 

Acute catarrhal gastritis. — Toxic gastritis. — Phlegmonous 
gastritis. — Gastric ulcer. — Gastric cancer. 

Dependent on Hepatic Changes. 

Cirrhosis of liver (by obstructing portal circulation). — Acute 
yellow atrophy. — Portal thrombosis. — Pressure on portal vein. 

Dependent on the Vessels. 

Traumatism. — Hemorrhagic diathesis (usually due to an ab- 
normality of the coats of the blood-vessels). — Pulmonary ob- 
struction (by producing tricuspid regurgitation). 

Dependent on the Blood. 

Malaria. — Scurvy. — Purpura. — Yellow f evei . 

Vicarious Causes. 

Hemorrhoids. — Menstruation . 

Intestinal Hemorrhage. 

Dysentery. -Typhoid fever.— Yellow fever.— Malarial poisoning. 

— Tuberculous ulceration. — Cancer. — Scurvy. — Purpura 

Traumatism. — Obstruction of portal vein. 

CAUSES OF HEMOPTYSIS. 

Those Situated above the Lung. 

Diseases of larynx.— Diseases of trachea.— Diseases of bronchi. 
(Such as Congestion, Inflammation, Ulceration, Cancer, etc.) 



28 



PROMINENT SYMPTOMS OF DISEASE 



In the Lung. 

Mechanical hyperaemia (from too high altitudes, and the in- 
halation of irritants). — Traumatism. — Pulmonary congestion. 
— Pneumonia, acute. — Pneumonia, chronic. — Abscess. — Gan- 
grene. — Apoplexy. — Phthisis. — Cancer. — Weak capillaries . — 
Aneurism of pulmonary capillaries. — Pleuritic adhesions 
(causing interference with the lung tissue). 

Mediastinal Causes. 

Tumors, pressing on the pulmonary vessels. 

Circulatory Causes. 

Aneurism of arch of aorta (breaking into a bronchus). — Mitral 
diseases. — Hypertrophy of right ventricle. — Dilatation of left 
ventricle. — Diseases of pulmonary vessels (as aneurism of pul- 
monary artery). — Aneurism of the arteria innominata, the 
carotid, or subclavian arteries opening into the air-passages. 

Nervous Causes. 

Vicarious menstruation. 

Blood Causes. 

Hemorrhagic diathesis. — Scurvy. — Purpura. 

CAUSES OF APHONIA. 

Inflammatory. 

Catarrhal laryngitis (acute and chronic). — Tuberculous laryn- 
gitis. — Syphilitic laryngitis. — Croupous laryngitis. — Diph- 
theritic laryngitis. 

New Growths. 

Cancer. — Polypi. — Vegetations. 

Mechanical Causes. 

Hemorrhage of vocal cords. — Paralysis of muscles of the larynx 
— Thickening of cords. — Spasm of cords. — Rupture of cords. 
CEdema of the larynx. — Foreign bodies in the larynx. — Exter- 
nal pressure upon the larynx. 

Nervous Causes. 

Injury to the brain in the region of origin of spinal accessory 
nerve. — Injury to the trunks of the pneumo-gastric or spinal 
accessory nerves. — Hysteria. — Mental excitement (from fright, 
anger, etc.).~Diphtheria.— Shock. 



POSSESSING A SPECIAL DIAGNOSTIC VALUE. 



29 



CAUSES OF HEMIPLEGIA. 
Cranial. 

Affecting the Bones. 

Depressed fracture. — Necrosis.— Caries. — Exostosis. — Cancer. 

Affecting the Meninges. 

Meningitis (9 varieties [see page 9J). — Tumors (Cancer, Tuber- 
cle, Cholesteatoma, Gummata, Myxoma, Lipoma, Psammoma, 
Hydatids, Cysts). — Meningeal hemorrhage. — Abscess (between 
dura mater and the bone). 

Affecting the Brain Substance. 

Cerebral softenings (red, white and yellow). — Cerebral tumors 
(see above and add "Glioma "). — Sclerosis. — Abscess. 

Affecting the Vessels. 

Thrombosis.— Embolism. — Apoplexy. 

Spinal. 

{Involving only the lateral half of spinal cord.) 

Affecting the Bones. 

Same as those among the cranial causes, with dislocation 
added. 

Affecting the Meninges. 

Spinal meningitis. — Cerebro-spinal meningitis. —Meningeal 
hemorrhage. — Tumors (same as those under cranial causes). 

Affecting the Substance of Spinal Cord. 

White softening. —Red softening or myelitis. — Tumors (same 
as those under cranial causes\ —Sclerosis of the cord. — Ab- 
scess of the cord. — Congestion of the €ord. — Apoplexy. 
Functional. 

Diphtheria. — Epilepsy. — Hysteria . — Chorea. — Poisons. 

CAUSES OF PARAPLEGIA. 
Spinal. 

Same as spinal causes of hemiplegia (provided both lateral halves, 
of the cord are involved). 

Functional. 

Anaemia. — Rl^umatism. — Syphilis. — Hysteria. — Diphtheria. 



PROMINENT SYMPTOMS OF DISEASE 



R :flex. 

Phymosis. — Diseases of bladder. — Diseases of uterus. — Diseases 
of intestinal canal. —Diseases of ovary. — Diseases of clitoris. 
--Diseases of kidney. 

CAUSES OF SUPPRESSION OF URINE. 
Acute active congestion of kidney. 
Blood-poison of yellow fever. 
Blood-poison of scarlet fever. 
Blood-poison of small-pox. 

Suppurative interstitial nephritis (following injury to or opera- 
tions on the urinary tract). 
Any inflammatory diseases may cause it. 

CAUSES OF RETENTION OF URINE. 

Dependent on the Urethra. 

Organic urethral stricture. —Hypertrophy of prostate. — Sup- 
puration of prostate. — Pressure on urethra from perineal 
abscess. — Pressure on urethra from perineal tumors. — Pressure 
on urethra from fracture of pelvic bones. — Rupture of 
urethra. — Calculus in urethra.— Spasm of urethral muscular 
fibres. —Congestion of urethral mucous membrane. — Fracture 
of penis. — Cancer of penis. — Polypus of the urethra. 

Dependent on the Bladder. 

Paralysis of the bladder. — Atony from over-distention or 
shock. — Cancer at neck of the bladder. — Vegetations at neck 
of the bladder. — Stone in cavity of the bladder. — Rupture of 
the bladder. — Pressure from tumors. 

CAUSES OF BLOOD IN URINE. 
Local. 

Dependent on the Kidney. 

Hyporsemia. — Cancer. — Pyelitis. — Infarction. — Stone in pel- 
vis. — Abscess. — Traumatism. -Parasites. 

Dependent on the Ureter. 

Cancer. — Traumatism. — Stricture. — Ulceration. — Impaction 
of calculus. 



POSSESSING A SPECIAL DIAGNOSTIC VALUE. 



Dependent on the Bladder. 

Cystitis. — Over-distention. — Cancer. — Stone in bladdef. — 
Vegetations . — Rupture . — Ulceration . — Traumatism. 

Dependent on the Urethra. 

Gonorrhoea — Chordee. — Chancre or chancroid. — Cancer. — Im- 
paction of a calculus. — Rupture of urethra. — Rupture of a 
prostatic abscess. — Fracture of penis. — Traumatism. 
Blood-Causes. 

All of the Fevers aiid Malarial Conditions. 

Poisons. 

Turpentine. — Copaiba.- -Cantharides. — Cubebs. — Alcohol. 
Scurvy. 
Purpura. 

Vicarious Causes. 
In connection with amenorrhoea. 
In connection with hemorrhoids, 

CAUSES OF PUS IN THE URINE. 

Dependent on the Kidney. 

Pyelitis. — Cancer of kidney. — Metastatic abcess of kidney.— 
Stone in the pelvis of kidney. — Perforation of peri-nephritic ab- 
scess. 

Dependent on the Bladder. 

Cystitis in all its forms. — Stone in the bladder. — Cancer of 
the bladder. 

Dependent on the Urethra. 

Cancer of the penis. — Prostatic abscess. — Ulceration.— Gonor- 
rhoea. —Urethritis. 

Dependent on the Adjacent Viscera. 

Escape of pus from other organs into the genito- urinary tract. 

CAUSES OF INSTANTANEOUS DEATH. 
In the Heart. 

Aortic regurgitation. — Heart-clot. — Rupture of the heart. — 
Angina pectoris. — Rupture of aneurism into the pericardial 
sac. — Fatty heart. 



32 PROMINENT SYMPTOMS OF DISEASE 

Dependent on Blood-vessels. 

Apoplexy. — Air in veins. 
Unclassified Conditions. 

Concussion of solar plexus. — Perforation of some abdominal 

viscera (from shock [?] ). — Sudden injury to brain or medulla 

oblongata (as occurs in apoplexy). 

TYPES OF EXPECTORATION. 

Muco-purulent. 

Occurs in phthisis— and is present in all forms of bronchitis, 
except croupous. — Appears after attacks of asthma. — Accom- 
panies emphysema, as a rule, since it is usually complicated 
by bronchitis. 

Pearls of Tenacious Mucus. 

Are frequently detected in emphysema. 

Pneumonic Sputa. 

Very tenacious at all times; at first, scanty and whitish; later 
on, pink or brick-dust in color; in bad cases, resembles " prune 
juice." 

Profuse- Watery. 

Occurs in pulmonary oedema (prominently). 

Gangrenous Sputa. 

Characterized by a putrid odor, and the presence of gangrenous 
shreds of lung-tissue (present in gangrene of the lung and 
in phthisis). 

Currant Juice. 

Occurs in cancer of the lung. 

Purident. 

May occur in abscess of lung; or in empyema, when the pleu- 
ral cavity communicates with a bronchus. — Occurs also in 
abscess of liver, by perforation of diaphragm and pleura. 
Fibrinous Casts. 

Present, in shreds or patches, in true membranous croup. 
Present in croupous bronchitis (when they resemble a tree in 
form). 

Sputa, u'ith Small Blood-Clots. 

Is usually characteristic of pulmonary infarction. 



POSSESSING A SPECIAL DIAGNOSTIC VALUE. 



33 



Sputa, Streaked with Blood. 

Present, as a rule, in tuberculous phthisis during the stage of 
deposit. — May exist also in a severe type of bronchitis and in- 
flammatory sore throat. 

Blood. 

Occurs in aneurism; pulmonary apoplexy; bronchial hemor- 
rhage. 

TYPES OF DIARRHOEA. 

Symptomatic. 

Typhoid fever. — Dysentery. — Cholera. — Exhaustion. — Mala- 
rial conditions.— Fatty diarrhoea. — Typhus (in later stages). — 
Tuberculosis (in later stages). 
Irritative. 

From indigested food, or any irritant (as cathartics, etc.). 
Sympathetic. 

In connection with worms. — In connection with dentition. — 
In connection with menstruation. — In connection with nerv- 
ous shock. — In connection with fright.— In connection with 
mental exercise. 
Eliminative. 

An evidence of nature's attempt to eliminate, through the in- 
testinal tract, some accumulated poison, or an excess of some 
. salt absorbed, as in the case of saline cathartics. 

CAUSES OF ALBUMINOUS URINE. 
Mollities Ossium. — Excessive use of albuminous food. — Irrita- 
tion of the renal nerves. — Irritation of the floor of the fourth ven- 
tricle. — Inhalation of irritants (as arsenuretted hydrogen and 
carbonic acid). — Dyspepsia. — Acute or Chronic Bright's Disease of 
the Kidneys (due to structural changes in those organs). — Preg- 
nancy and the puerperal state (due to obstruction of the renal 
veins from pressure or an excess of excrementitious substances in 
the blood to be eliminated by the kidney). — The various fevers, as 
typhoid fever, scarlet fever, measles, yellow fever, small pox, 
cholera, ague, diphtheria, (due to pyrexia and the operation of a 
specific poison indicating serious structural changes in the kid- 



84 



PROMINENT SYMPTOMS OF DISEASE 



neys). — Certain inflammatory diseases, such as articular rheuma- 
tism, peritonitis, pneumonia, traumatic fever, etc : — Obstruction 
to the circulation of the blood, as occurs in emphysema, valvular 
heart lesions, abdominal tumors, cirrhosis of the liver, atheroma, 
etc : — An hydrsemic and disordered state of the blood and atony 
of the tissues, as in purpura, scurvy, pyaemia, hospital gangerene, 
also hasmatinuria ; and finally saturnine intoxication. 

CAUSES OF CHYLOUS URINE. 

Long residence in tropical climates. — A fall or shock to the ner- 
vous system. — Excessive mental or bodily work. — Cessation of 
lactation. — Tuberculosis of the lungs. — Fatty stage of parenchy- 
matous nephritis. — Some derangement of the process of assimila- 
tion causing an elimination of food elements by the kidneys. — 
Some imperfectly understood derangements of the submucous 
tissues of the urinary passages or bladder. — Hypertrophy of the 
lymphatic or lacteal vessels, or the inguinal glands (which become 
enlarged and tumified and ultimately discharge then* contents in- 
to the urinary passages. — It may possibly be caused by minute 
parasites which infest tbe urinary passages (?). 

Characteristicj of Chylous Urine : 

(1st.), a wliitish or milk color. — (2), more or less j^erfed sponta- 
neous solidification of the urine on standing, which in marked 
cases may allow the urine to be turned out like a jelly from 'one 
receptacle to another.— (3), a strongly albuminous reaction to heat 
and nitric acid, and (4), the presence of fat globules in a condition 
resembling that of chyle when examined bv the microscope. 

CAUSES OF HEPATIC ABSCESS. 
Varieties. — Acute, chronic, metastatic or pyeemic, and inflam- 
mator}'. Wounds and contusions ; impaction in the gall-ducts 
of angular substances ; ulcerations or gangrenous affections of 
the abdominal organs; embolus of the branches of the portal vein 
or some injurious irritating matter, carried to tlie liver through 
the portal vein, or some other vein as the hemorrhoidal ; inflam- 
mation of the parenchyma (Glisson's capsule) from injuries, sup- 
puration, thromboses and inflammation of the veins ; inflamma- 
tion and suppuration of the gall-bladder or gall-ducts; exposure to 
vicissitudes of temperature (especially in hot countries); malar- 
ious poisons: cold; nervous depressions; pregnancy; drunkenness. 



DISEASES OF THE RESPIRATOEi 
OEGAIvrS. 



DISEASES OF THE LARYNX. 



These may be primary, when the larynx is first affected, and of 
a purely local type; or secondary, when the disease occurs as a 
complication. 

VARIETIES. 
Catarrhal laryngitis, acute and chronic. 

CEdema glottidis, or inflammation of the submucous tissue of the 
larynx. 

Croupous laryngitis, or " membranous croup." 
Ulcers — which may be catarrhal, typhus, variolus, tubercular, or 
syphilitic. 

Nervous affections — spasm and paralysis. 

New formations — polypi, cancer, tubercle, ossification of carti- 
lages, etc. 

ACUTE CATARRHAL LARYNaiTIS. 
DEFINITION. 

Is an inflammation of the mucous membrane of the larynx, of 
either a partial or general character, resulting in catarrhal pro- 
ducts, 

MORBID ANATOMY. 
The mucous membrane of the larynx will be found to be red, 
swollen, and softened, audits surf ace covered with mucus, contain- 
ing epithelial or pus cells. When the deeper tissues are affected, a 
tumefaction of the parts may take place, from accumulation of the 
inflammatory products beneath the mucous membrane ; which 
may be attended with great danger. Erosions or ulcers may occur, 
accompanied by ecchymosis of the membrane, and escape of 
blood into the secretions (due to rupture of the capillary vessels). 

ETIOLOGY. 
Predisposing Causes. 
Badly nourished, cachectic subjects. — Constitutional vice. 



38 



DISEASES OF THE RESPIRATORY ORGANS. 



Exciting Causes. 
Chilling of the surface (by exposure). — Mechanical violence. — In. 
halation of irritant gases, etc. — Exanthematous fevers (chiefly 
typhus). Blood poisons (diphtheria, syphilis, etc.). — Tonsil- 
litis. — Erysipelas. — An accompanying influenza or bronchitis. 

SYMPTOMS. 
Rational. 

The approach is insidious. 

Sore throat and constriction exist. 

Cough— is at first harsh and stridulous, becoming metallic as the 

disease increases. 
Tenderness on pressure over the larynx. 
Tickling sensation in the throat. 
Dyspnoea. 
Dysphagia. 

Prolonged and wheezing inspiration and expiration, if the inflam- 
mation is severe. The patient is often unable to lie down on 
this account. 

Expectoration — (if any) is tenacious at first, and, later on, is thick, 

purulent, and abundant. 
Face — flushed at onset (the skin is usually hot and dry). 
Countenance — pale and anxious as the disease increases. 
Temperature — elevated — 105° . 
Pulse — hard and frequent. 

Drowsiness, suffocation and cyanosis — from imperfect aeration of 

the blood. 
Delirium — in severe cases. 
Coma — in severe cases. 
Death — in severe cases. 

Physical. 

Inspection — respiration at first is labored, but, later on, may 

become of a gurgling and gasping type. 
Auscultation — a feeble vesicular murmur is heard over the lungs 

— which may be entirely absent. 
On Laryngeal Examination. 

The mucous membrane is found to be bright-red. If severe, 



ACUTE CATARRHAL LARYNGITIS. 



39 



there may be oedema ; the parts are red, swollen, and semi- 
transparent, and the oedema is usually on the ventricular folds. 
These changes may extend to the trachea, or remain in the 
mucous membrane of the larynx or of the epiglottis. 

DIFFERENTIAL DIAGNOSIS. 
Croupous laryngitis, diphtheria, oeiema laryngis, spasmodic 
asthma, hysteria, laryngeal spasm, thoracic aneurism, may be 
mistaken for this disease. In very young children, it must be dis- 
tinguished from croupous laryngitis, which is seen by the laryngo- 
scope as a false membrane; but the history, constitutional 
symptoms, and physical examination will stamp either of the 
other diseases. 

PEOGNOSIS. 

In adult's, it depends upon the amount of oedema present. 
In infancy, if it is severe, the disease is always fatal. 

CAUSE OF DEATH. 
Death may occur in a few hours from oedema glottidis, if the 
attack be severe ; but if mild, five to eight days usually elapse be- 
fore death occurs. It is caused from closure of the rima glottidis, 
from swelling of the mucous and submucous tissues, and it may 
also occur from pulmonary or cerebral congestion. 

TREATMENT. 

Venesection— only if the patient is robust, and there is a likeli- 
hood of syncope. A warm, moist, uniform temperature is essen- 
tial. The temperature of the room should never be below 76° F. 
Absolute rest to the larynx is all-important. Vapor inhalations 
should be resorted to early in the disease and persevered with. 
Quinine ^hoMld. be given in large doses and cinchonism produced; 
for a child three years of age, gr. xx. may be administered during 
the first twenty-four hours, if it is suffering from a severe attack. 
If there is oedema, the parts should be scarified, or tracheotomy 
performed, if you are unable to scarify; but tracheotomy may 
cause the inflammation to extend to the trachea, and result in 
pneumonia and bronchitis. 



40 



DISEASES OF THE RESPIRATORY ORGANS. 



CHRONIC CATARRHAL LARYNGITIS. 
SYNONYM. 

" Clergyman's sore throat."— Laryngeal Phthisis. 

DEFINITION. 

Is a chronic inflammation of the lining membrane of the larynx 
(which may be general, or partial, or manifest a tendency to remain 
stationary), and in which the vessels of the areolar tissue slightly 
participate. 

MORBID ANATOMY. 
When fully developed, the mucous surface is usually coated 
with mucus or pus, and is of a dark or grayish-red or blue color, 
due to ecchymosis, and may be softer or firmer than normal. 
The glands are enlarged and prominent; and there may also be 
erosions, fissures, ulcers, polypi, etc. Sub-mucous thickening 
and oedema may also occur, producing considerable narrowing of 
the glottis. The epiglottis may often be eroded. 

ETIOLOGY. 
Predisposing Causes. 
Pharyngeal inflammations (from alcoholism or tobacco in ex- 
cess).— Chronic bronchitis of old age. — It may be a primary 
disease, or a sequela of acute laryngitis. 

Exciting Causes. 
Irritating inhalations. — Morbid growths (laryngeal). — Pulmonary 
phthisis, syphilis, etc. — An extension of a laryngeal, catar- 
rhal, or follicular faucitis (when the racemose glands of the 
larynx are principally affected). 

SYMPTOMS. 
Rational. 

. Voice. 

Chronic hoarseness, or a husky whisper, or an ultimate loss of 
voice. 



CHRONIC CATARRHAL LARYNGITIS. 



41 



Cough. 

Hoarse or stridulous. 
Expectoration. 

Muco-purulent or purulent (possibly streaked with blood). 
(Edema — as shown by the laryngoscope. 
Pain and tenderness on pressure over the larynx. 

Physical. 

Auscultation. 

Moist rales over the larynx may be detected. 

Laryngoscopic examination. 

Shows general or partial hypersemia of the lining membrane, 
and dilatation, or contraction of the larynx ; a muco-purulent 
secretion on the mucous membrane ; or, the membrane may 
be dry and shining in appearance. — The orifices of the glands 
may be seen as pale specks on the congested membrane, or 
as red circles. In syphilitic or phthisical patients, in addition 
to the above symptoms, there may be thickenings, ulcera- 
tions, or papillary excrescences.— Chronic oedema, of one or 
both of the aryteno-epiglottidean folds, is often observed in 
the chronic laryngitis of phthisis. 

DIFFERENTIAL DIAGNOSIS. 
From laryngeal growths; nervous affections; pulmonary phthi- 
sis (when examination of the lungs decides); and syphilis (where 
the history decides). 

PROGNOSIS. 

Depends upon the pathological associations. 

Recovery is rare, if it occur in connection with pulmonary 
phthisis; the chances of recovery are better if it depend on syphilis, 
but the voice is permanently affected, as a rule. 

Is usually good, unless complications exist.. The disease is 
rarely fatal in itself. 

TREATMENT. 

Local internal applications should be frequently applied to the 
diseased tissues. A solution of nitrate of silver (gr. Ix. to | i. of 
water), or chloride of zinc (gr. xxx. to 3 i. of glycerin), is often 
used with benefit. 



42 



DISEASES OF THE RESPIRATORY ORGANS. 



Inhalations with either of the following prescriptions may be 
applied for five minutes at a time, three times a day : I?. 01. pini, 
3ij.: Mag. carb.,gr. ij.; Aquae, §ij.; Sig. one drachm in a pint 
of hot water (at 150° F.).— Creasoti, 3 iij. ; Glycerinee, 3iij., 
Aquse, § iij ; or 01. juniperis, m 1.; Mag. carb., gr. x.: Aquae, 
§ij.; or I? Acid, carbol., 3ss.; Glycerinae, 3ij.; Aquae, §ij. 

Nebulized liquids, or spray of either of the following drugs, 
should, like the inhalations, only be continued for five minutes at 
a time : alum, perchloride of iron, tannin, or sulphate of zinc, 
from gr. i.-xx. to the ounce of water. 

Rest of voice is imperative, and the patient should be removed 
to a warm dry climate . If the disease is due to syphilis, potassium 
iodide should be administered in large doses, and the pitient put 
under proper hygienic treatment ; or, if due to phthisis, the 
general treatment of phthisis is indicated. 

(EDEMA GLOTTIDIS. 
DEFINITION. 

Is a dropsical effusion, usually of inflammatory origin, in the 
areolar tissue above the vocal bands; or. in other words, an oedema 
of the upper portion of the larynx. 

MORBID ANATOMY. 

The changes that occur in this disease are principally observed 
during life; as, after death, owing to the disappearance of the 
greater part of the effusion, the mucous membrane is found to be 
wrinkled, and probably a very small quantity or only a trace of 
the effusion can be found. 

On examination, during life, a tumor, about an inch or so in dia- 
meter, may be observed projecting, on one or both sides, into the 
cavity of the larynx and often into the pharynx, which may com- 
pletely close the laryngeal opening. The mucous membrane may 
be either red or pale. The serous effusion commences in the loose 
cellular tissue beneath the mucous membrane, principally in the 
aryteno-epiglottidean folds, at the base of the epiglottis. When 
the tumor is pricked, a clear, turbid, or purulent fluid escapes. 



CEDEMA GLOTTIDIS. 



43 



Collapse of the tumor and wrinkling of the mucous membrane 
then take place. 

ETIOLOGY. 

The predisposing causes are: constitutional disturbance; any in- 
flammation of adjacent tissue, or local irritation (as acute laryn- 
gitis); erysipelas; deep-seated cervical abscesses ; acute tonsillitis ; 
laryngeal ulceration; due to typhus, typhoid, scarlatina, and 
small-pox ; Bright's disease; venous obstructions in cardiac dis- 
eases; and thoracic aneurism. 

SYMPTOMS. 
Rational. 

Dyspnoea on inspiration, (often alarming). 
No fever or constitutional disturbance. 
Suffocative breathing (often the first indication). 
Paroxysm of strangulation. 
Cyanosis. 

Veins prominent (due to obstructed venous return). 
Drowsiness (due to approaching cyanosis). 
Cold extremities. 

Inclination to rid the upper part of the throat of some supposed 
secretion. 

Physical. 

The laryngoscope reveals two small tumors, about one-half an 
inch to one inch in length, which are at first smooth and 
round and possibly oval, situated at the ventricular folds, thus 
causing difficulty in laryngeal respiration. 

DIFFERENTIAL DIAGNOSIS. 

Is easy, on account of the circumstances under which it is de- 
veloped, together with the sudden occurrence, and the peculiar 
character of the respiration ; the absence of febrile symptoms, 
and the aid of the laryngoscope confirm the diagnosis. 

PROGNOSIS 
Is fatal, if not properly attended to. 



44 



DISEASES OF THE RESPIRATORY ORGANS. 



TREATMENT. 

Prompt surgical interference, as laryngotomy, tracheotomy, or 
scarification are the only means of relief. Medications are of no 
avail. 

ACUTE CROUPOUS LARYXOITIS. 
DEFINITION. 

A fibrous inflammatory exudation of the larynx, which usually 
commences on the tonsils and often extends to the trachea and 
bronchi. 

MORBID ANATOMY. 
There exists on the mucous membrane a whitish or yellowish- 
white fibrinous layer, often covered with dots or lines. This mem- 
branous exudation may be in patches, or form a cylinder, extend- 
ing into the trachea or bronchi. It may be firm in consistence, 
and adhere with great tenacity to the subjacent membrane, or it 
may be soft and easily separated. The surface is smooth, and 
adheres with great firmness to the vocal cords and upper part of 
the epiglottis (which possesses pavement epithelium). The mem- 
brane may be cast off in the form of a cylinder, or shi'eds, in 
consequence of the damming up of the secretion of the follicles, 
as- well as by the serous exudation from the previously inflamed 
membranes. It may be expectorated, or undergo granular, fatty, 
or mucous degeneration, thus resembling. a mucous fluid ; there- 
fore, in the latter case, no membranous exudation is observed. 
Under the microscope it will be seen that there are generally pus 
and rarely epithelial cells. It is questionable whether these are 
changed epithelial cells or white globules. The mucous mem- 
brane, like all inflamed tissues, contains a varying amount of 
these cells. As the exudation is cast off, the surface epithelium 
is quickly repaired, and the laryngeal membrane returns to its 
normal condition. 

STAGES AND DANGERS OF THE DISEASE. 
1st Stage — Precursory or catarrhal. There is danger of the form- 
ation of a membrane in the trachea and larynx, if the inflam- 
mation continue downward. 



ACUTE CROUPOUS LARYNGITIS. 



45 



2d Stage — Development. There is danger of inflammation con- 
tinuing to the minute bronchi. 

3d Stage — Suffocation or collapse. There is danger to the patient 
from exhaustion and carbonic acid poisoning. 

ETIOLOGY. 

Occurs between dentition and puberty. Rarely in very young 
infants or adults. 

Predisposing Causes. 
Occurs in delicate, v^eakly, ill-fed children. 

Exciting Causes. 

From exposure to cold and moisture. — From sudden alteration in 
temperature. — From irritation of hot water, etc., applied to 
the larynx. — Follows eczematous eruptions on the head and 
face, and frequently measles, scarlatina, and small-pox. 

SYMPTOMS. 
Precursory or Catarrhal Stage. 

Rational. 

Catarrh — mucous membrane red and tumefied. 
Slight hoarseness. 

Cough — noisy, high-pitched, stridulous. 
Crowing noise after the cough. 
Dysphagia — (puts the hand to the throat). 
Pulse — accelerated, full, and hard. 
Temperature of axilla— 102° to 105°. 
Fever — intermittent, 
lledness of the face. 
Dyspnoea — most severe at night. 
Physical. 

Inspection — difficult respiration. 

Stage of Development, 

Rational. 

Aphonia — speaks or cries in a whisper. 
Cough — suppressed and more stridulous. 
No expectoration. 

Head thrown back (an evidence of dyspnoeaX 



46 



DISEASES OF THE RESPIRATORY ORGANS. 



Physical. 

Inspection — difficult respiration; during inspiration there is a 
contraction of the lower part of the chest and sinking 
above the clavicles. Epigastrium is depressed, and there 
is arrested expansion of ribs. 

Auscultation — feeble vesicular murmur. 

Stage of Suffocation or Collapse, 

Batiojial. 

Nostrils — dilated. 
Great restlessness. 

Countenance — pale and livid (expression of fear often present). 

Pulse — rapid and feeble. 

Temperature — falls below normal. 

Cold extremities. 

JDrowsiness. 

Gasping. 

Cyanosis. 

Paroxysmal dyspnoea. 

Coma 

Death. 

DIFFERENTIAL DIAGNOSIS, 
From simple catarrh of the larynx ; (spasmodic or pseudo croup) in 
nervous subjects; purely spasmodic affections of the larynx 
(in each of which the spasm gives rise to croupy symptoms); 
diphtheria involving the laiynx. 

PROGNOSIS. 

In childhood, this is the most fatal of all the diseases (especiaUy if 

membranous exudation occurs On the tonsils and epiglottis). 
Favorable signs — if the paroxysms of dyspnoea are diminished in 

frequency and severity; if the breathing is not so distressed; 

if there is a gradual return of voice, and a moist sound with 

the cough. 

A fatal result is indicated if the dyspnoea become more frequent 
and violent; the cough less powerful and stridulous; and when 
there is marked cyanosis and drowsiness. 

The recovery is slow. It may be weeks before the patient regains 



BRONCHITIS. 



47 



the use of the voice, and violent dyspnoea may occur during 
the whole period of recovery. 

TREATMENT. 

In the very early stage give turpeth-mineral, Hyd. sulph. Jlavce^ 
gr. ij., or (as it is better known) "German croup powder." Pa- 
tient should be placed in a large, well-ventilated room, with a 
temperature about 75 to 80^ ; and the air should be moistened by 
steam, etc., as in other laryngeal affections. Administer Quinine, 
gr. XXX., in gr. v. doses to a child to arrest inflammation. A 
moist, nutritious diet should be given from the onset of the dis- 
ease, together with stimulants if a failure of the vital power be- 
come apparent. 

Tracheotomy (?) is only a temporary relief, and must be done 
early in the disease or not at all. 

BRONCHITIS. 
DEFINITION. 

Is an inflammation of the mucous membrane of the trachea and 
bronchi, which may vary in extent, intensity and duration. 

VARIETIES. 

Acute catarrhal. — This form may be simple or capillary; and 
localized or general. It occurs in infancy and old age, froni acute 
catarrhal inflammation, typhus, and measles; first affecting the 
large tubes, and by passing downward to the smallest tubes, often 
becomes capillary in form. In middle life, it affects the larger 
bronchi. 

Chronic catarrhal. — This is a secondary affection. Is a low 
grade of inflammation of the bronchial mucous membrane, and a 
disease of adult life, having a tendency to recur, with increased 
vigor, till it becomes permanent. 

Croupous or plastic. — This may be acute or chronic. This is a 
very rare form of the disease. Is met with in the young adult, prin- 
cipally in the female, and those of feeble or delicate constitutions. 
In acute fatal cases, it only lasts from three to ten days; but, in 



48 DISEASES OF THE RESPIRATORY ORGANS. 

those likely to recover, its duration is about fourteen days. Com- 
plete recovery is, however, exceedingly rare- 

ACUTE CATAERHAL BRONCHITIS. 

MORBID ANATOMY. 

This disease is the continuation of an inflammation which 
usually commences in the nasal, pharyngeal, or laryngeal mucous 
membrane; or the inflammation may commence in the alveoli and 
extend to the smaller tubes. The mucous membrane is found to be 
swoUen and red, softer and more moist than normal, and occasion- 
ally ecchymotic. A clear transparent mucus is at first contained in 
the bronchi, which, as the disease progresses, becomes opaque, 
whitish, yellowish, greenish, or muco-purulent; this change is 
owing to an increased number of cells contained in the fluid 
(which are pus cells), and also to the presence of epithelium (often 
of the ciliated variety). 

On a post-mortem examination, the presence of mucus or muco- 
pus in the tubes may be the only evidence of bronchitis; these 
same changes may exist whether the large or small tubes are 
affected. Yellow spots may be found on the surface of the lung, 
occurring in young, feeble children, from gravitation of mucus or 
muco-pus from the larger into the smaller tubes. The accumula- 
tion of this mucus or muco-pus may produce a temporary obstmc- 
tion, and distention of the alveoli, which may be mistaken for vesi- 
cular emphysema. 

ETIOLOGY. 
Predisposing Causes, 
Infancy and old age, — Indulgence in enervating habits. — Debility, 
from any cause,: — Constitutional disease (as gout, syphilis, 
etc.). — Chronic pulmonary affections (phthisis, emphysema, 
etc.). — Bad air. 

Exciting Causes. 
Chilling of the surface of the body. — Secondary result of blood 
poisoning. — Irritation, produced by substances inhaled. — 
Atmospheric conditions. — Heart lesions (as mitral stenosis or 



ACUTE CATARRHAL BRONCHITIS. 



49 



insufficiency, or tricuspid regurgitation). — Pressure on the 
aorta below the bronchial arteries, or from fluid in the peri- 
toneal cavity, or gas in the intestines pressing the blood back 
in the abdominal aorta, thus causing congestion of -the lungs 
and the bronchial tubes. 

SYMPTOMS. 
Rational. 

Stage of Invasion. 

Coryza. — Uneasy sensation in the frontal sinuses, extending 
down the nasal passage to the larynx and trachea. — Aching 
in the back and limbs; convulsions may occur in children. 

Pain and discomfort behind the sternum. 

Sense of soreness on coughing. 

Sense of constriction in the chest. 

Cough. 

In the early stages is dry or hacking. — In the later is loose in 
character. 
Expectoration. 

Frothy mucous, muco-purulent, or purulent. 

Physicial. 

Inspection and palpation are negative. 

Auscultation — Sibilant and sonorous rales (in the dry stages); or 
large and small mucous rales after the disease is fully de- 
veloped (which change their position on coughing). 

DIFFERENTIAL DIAGNOSIS. 
From pneumonia and pleurisy; but the symptoms of the stage 
of invasion and the physical signs are sufficient to distinguish it 
from either. 

PROGNOSIS. 

Never destroys life directly, unless it occur in very young chil- 
dren; as it usually terminates in resolution, or becomes chronic 
The inflammation may, however, sometimes extend to the smaller 
tubes, resulting in capillary bronchitis or lobar pneumonia. 

TREATMENT. 

In the stage of invasion, a Dover's powder, and a warm bath at 



50 



DISEASES OF THE RESPIRATORY ORGANS. 



night, followed in the morning by a brisk saline cathartic (for 
children a full dose of castor oil), may be all that will be required 
to avert the attack. The patient must be kept in a warm room 
of equal temperature for a few days. 

In the early stage, great benefit is derived from inhalations of 
the vapor of molasses and water; or from mustard poultices ap- 
plied to the upper part of the chest. 

Quinine gr. viij-x. should be given daily if the disease is likely 
to pass into the chronic stage, or to extend to the smaller bronchi. 
Oleum morrhuce, with lime-ivater, should also be given; but if it 
occur with gout or rheumatism, give colchicum loith alkalies. 

ACUTE CAPILLAKY BEONCHITIS. 
DEFINITION. 

It is an extension of acute catarrhal inflammation into the 
small-sized bronchial tubes, and may be localized or diffused. 

Localized — if the inflammation is limited to the smaller tubes. 

Diffused — when the inflammation attacks the lining membrane 
of all the bronchial tubes. 

MORBID ANATOMY. 
Is the same as in acute catarrhal bronchitis. 

ETIOLOGY. 
The same as in acute catarrhal bronchitis. 

SYMPTOMS. 
Rational. 

Dyspnoea — marked (patient unable to lie down). 
Recurring chills. 

Febrile symptoms often well marked. Temperature 100= to 103°. 
Pulse 100 to 130, and feeble. 

Respiration— labored and frequent; 60 to 70 per minute. 
Cough — violent at first; is usually hacking in character. 
Expectoration — at first, of a thick tenacious mucus; later on, It 

becomes more abundant, less tenacious, thin, and frothy 
Exhaustion — marked. 



ACUTE CAPILLARY BRONCHITIS, 



51 



Coantenance — anxious and flushed; in later stages, livid. 
Great restlessness — (^later on in the disease). 

Palse — becomes small and thready as death approaches; is alwaj^s 

raised in frequency. 
Body — is covered with a cold, clammy sweat as death approaches. 
Delirium — muttering. 
Coma — partial. 

Death — from apnoea (from imperfect oxygenation of the blood). 
Physical. 

Percussion — is exaggerated in the infra-clavicular regions (unless 
oedema exist). 

Auscultation — diminished respiratory murmur. — High-pitched 
sibilant rales. — Suhcrepitant rales, as the disease advances. 

DIFFERENTIAL DIAGNOSIS. 
From pneumonia; pulmonary oedema; acute and chronic 
phthisis. 

PROGNOSIS. 

When general capillary bronchitis occurs in infancy or old age, 
or follows phthisis, Bright's, heart disease, or any acute blood dis- 
ease, it is always attended with great danger. 

If there is difficulty of expectoration, signs of accumulation in 
the bronchial tubes, shallow breathing, cessation of cough, dys- 
pnoea, apnoea, or failure of heart's power, the prognosis is un- 
favorable. 

TREATMENT. 

The patient must be kept in bed the surface of the body covered 
with flannel, the temperature of the room be about 70°, an.d the 
air moistened with steam. The diet should be of a concentrated 
nutritious nature as milk, eggs, etc. Dry cups must be applied 
to the chest which should afterwards be covered with an oil-skin 
jacket. Steam inhalations should be used freely, as it increases 
the secretion and facilitates expectoration. 

Give muriate of ammonia and cldorate of potassium gr. v.-x., 
every two hours to an adult (gr. ij. to a child two years of age). 

If expectoration is entirely absent, give stimulating emetics. 



52^ DISEASES OF THE RESPIRATORY ORGANS. 

Should the pulse become small and thready, give quinine and 
brandy. Stimidants require to be administered judiciously early 
in the disease and continued. 

If there is spasm of the bronchial tubes, full doses of hydro- 
cyanic acid may markedly relieve, but never give opium. 

OHEONIO CATAEEHAL BEO^nTCHITIS. 
DEFINITION. 

Is a low grade of inflammation of the broncnial mucous mem- 
brane, having a tendency to recur with increased severity and 
duration, tiU it becomes permanent. 

It may be primary or secondary. Primary, when it results from 
external causes; and secondary, when it results from some pre- 
viously existing or constitutional dyscrasia. 

MORBID ANATOMY. 
The inflammation may be limited to the large bronchi, or it 
may extend into the capillary tubes. The bronchial mucous 
membrane has a gray or reddish-blue color, and, in chronic cases, 
is often hypertrophied. Its glands are enlarged and prominent, and 
their ducts so increased in size that their mouths are readily 
visible. In the early stage, the other coats of the bronchial tubes 
may be weak or yielding; and later on, there may be thickening 
and induration. The results of chronic bronchitis are dilatation 
and stenosis of the bronchial tubes; an accumulation of secretion 
in a state of cheesy degeneration (obstructing their calibre); and 
pulmonary emphysema and induration of the adjacent lung-tissue. 

ETIOLOGY. 

Predisposing Causes. 
Exposure to cold or wet. 
Bad air. 

Constitutional diseases (gout, etc.). 

Exciting Causes. 
Irritation by substances inhaled. 
Mitral stenosis. 
Chronic alcoholismus. 



CHRONIC CATARRHAL BRONCHITIS. 53 

SYMPTOMS. 

Rational. 
In Early Stage, or simplest form. 
Cough — at first, may be slight. 

Expectoration — muco-purulent, which comes on in the winter 
and disappears in the summer, and ultimately" becomes 
permanent. 
Later on in the Disease. 

Cough — is violent, (especially in the morning). 

Expectoration — tenacious and scanty, or thin, semi-trans- 
parent, and abundant, sometimes streaked with blood and 
difficult to expectorate ; varies from an ashy yellow to a 
dark-green color, and sinks in water. 

Emaciation— (may occur). 

Fever — (may occur). 

Night sweats— (may occur). 

Dyspnoea. 

Pulse — is normal. 

Temperature — is normal (except where there is a foetid breath). 
Soreness behind the sternum (increased by coughing). 

Physical. 

Inspection — respiration is accelerated and labored. 
Palpation — vocal fremitus may be normal, exaggerated, dimin- 
ished, or absent. 
Percussion — normal, or temporary dullness. 

Auscultation — vesicular murmur is more or less deficient, and the 
respiratory sound is coarse, loud, and harsh, with prolonged 
expiration. There may be large or small mucous rales which 
are altered in character and position by coughing, and by a 
full inspiration. Vocal resonance is normal, diminished, or 
slightly exaggerated. 

DIFFERENTIAL DIAGNOSIS. 

From pleuritic effusions; pneumonic consolidation; and pulmo- 
nary phthisis. 



54 



DISEASES OF THE RESPIRATORY ORGANS. 



PROGNOSIS. 

This disease rarely destroys life directly; but, if associated with 
any pulmonary affection, the condition of the patient is serious, 
on account of the liability to obstruction from the accumulation 
of the secretion in the bronchial tubes. When it occurs in per- 
sons past middle life, recovery is rare. 

TREATMENT. 

Remove the patient from every source of bronchial irritation, 
and guard against exposure to changes of temperature. Flannel 
should be worn next to the chest. Keep the patient in the house 
in bad weather. See that the apartments are well ventilated and 
at a temperature of about 65^ to 70° F. The patient must not be 
allowed to expose himself to the night-air or cold winds, and, if 
possible, should be sent to a warm, dry climate. If there is severe 
emaciation, a long sea voyage is advisable. The diet should al- 
ways be nutritious, and a moderate amount of stimulants will be 
necessary. 

If a rheumatic or gouty diathesis exist, then give colehicum and 
alkalies. Iodide of potassium should be administered internally 
if the disease be associated with pulmonary emphysema. 

If there be anaemia, iroii is indicated and a general tonic treat- 
ment, when quinine, mineral acids, bitter vegetable infusions may 
be combined with iron. If the bronchial secretions are excessive, 
steam inhalations of tar, creasote, and naphtha are of great ser- 
vice. When the expectoration is deficient, stimulating expector- 
ants, such as senega, serpentaria, camphor, tincture of benzoin, 
combined with carbonate of potash, soda, etc. , are indicated. 

If the bronchial mucous membrane is irritable, the secretion 
scanty, and the cough paroxysmal, opium, hydrocyanic acid, 
hyoscyamus, belladonna, or eonium should be administered in 
full doses. 

If the bronchial secretion accumulate in the larger bronchi and 
cannot be expectorated, emetics may be employed. 



CROUPOUS BRONCHITIS. 



55 



CROUPOUS BEONCHITIS. 
SYNONYM. 

" Plastic bronchitis." 

MORBID ANATOMY. 

It differs from catarrhal bronchitis, since plastic material is 
poured out into the tubes in the form of casts, which are either 
solid or hollow, according as the large or small tubes are affected, 
and are of a whitish color, sometimes dotted over with blood spots. 

In the chronic form, the membranous exudation occurs only 
over a circumscribed portion of the bronchial membrane ; in the 
acute, it is distributed over a greater portion of the bronchi. The 
membrane may be firmly adherent, or loosely attached to the 
mucous surface. The casts under the microscope consist of fib- 
rillated fibrin, abundant granular matter, exudation corpuscles, 
and ovoid cells. 

ETIOLOGY. 

It is most frequently met with in the young adult, especially in 
females, and in those of a feeble and delicate constitution. It is 
said to be due to some diathetic state. 

It may be acute or chronic, but both forms are rare; the acute is 
the most infrequent. 

SYMPTOMS. 
Rational. 

Fever. 

Cough — which is hoarse and ringing in character. 

Dyspnoea— (of ten severe). 

Haemoptysis. 

Expectoration — consists of casts of the bronchial tubes (often re- 
sembles trees with short branches). 
Death — may result from asphyxia. 

Physical. 

Percussion — may be normal, extra resonant, or dull. 



56 



DISEASES OF THE RESPIRATORY ORGANS. 



Auscultation — Respiratory murmur is feeble ; or absent, if the 
bronchial tubes are obstructed. Dry or moist rales are usually 
present. 

DIFFERENTIAL DIAGNOSIS. 
From acute catarrhal bronchitis ; pneumonia : or pleurisy. 

PROGNOSIS. 

In the acute form (which lasts from three to ten days) more 
than half die. In the chronic form, wliich lasts from ten to four- 
teen days, if it is not compUcated, the prognosis is good as regards 
life, but having once occurred is apt to return. Complete recovery 
is rare. It is very likely to lead to pneumonia and phthisis. 

TREATMENT. 

In the acute form, the treatment is the same as in croupous 
laryngitis. In the chronic form, alkaline steam inhalations should 
be used during the paroxysm, and the patient kept in a warm 
equable temperature. During the interval, iodide of potassium, 
quinine, iron, and cod-liver oil have been recommended. If the 
paroxysms return, the patient should be sent to a warm chmate, 
or on a long sea voyage. 

ASTHMA. 
Definition. 

Is a condition produced by spasm of the involuntary muscular 
fibre of the bronchial tubes. 

MORBID ANATOMY. 
This disease is looked upon as a spasmodic affection of the 
bronchi causing dyspnoea. These bronchial contractions ai'e due 
to a reflex nervous action ; and the disease may be regarded as a 
neurosis, dependent upon the existence of a peculiar diathesis. 
Catarrhal symptoms may be wanting, and, when present, may 
precede the paroxysm. These attacks may occur in those suffer- 
ing from organic diseases of the heart, or lungs, but tme asthma 
is spasmodic. 



ASTHMA. 



57 



ETIOLOGY. 

Hereditary predisposition ; irritation of the mucous membrane 
of the bronchi by certain atmospheric changes ; reflex irritation, 
from abnormal conditions of the nervous system, or of organs ; 
or as a complication of some other disease. 

SYMPTOMS. 
Eational. 

Premonitory symptoms (peculiar to the individual) are present in 

some cases, as drowsiness, wakefulness, headache; etc. 
Dyspnoea — intense and of sudden onset. 
Respiration — wheezing. 

Posture — sitting {arms braced, mouth open). -. 

Face — red, or livid, and anxious. 

Extremities — blue and shrunken in prolonged^cases. 

Cough and expectoration (after the attack) whifch may consist of 

mucous or be profuse and watery. 
Sense of extreme exhaustion — after the attack has subsided. 
Physical. 

Percussi07i — exaggerated. 

Auscultation— high-pitched, sibilant, and sonorous rales. 
Kespiratory murmur — is jerking or exaggerated and usually short. 

DIFFERENTIAL DIAGNOSIS. 
From acute capillary bronchitis ; pulmonary .oedema ; pulmo- 
nary congestion ; hydro-thorax ; angina pectoris ; and laryngeal 
obstruction. 

PROGNOSIS. 

Is seldom, if ever, directly a cause-* of death. This class of 
patients are generally long-lived, as they have to attend most 
rigidly to all the principles of hygiene. 

TREATMENT. 

It should be borne in mind that you must first relieve the 
paroxysms, and then prevent their occurrence. In order to accom- 
plish this end, it will be your duty first to ascertain the cause, 



58 



DISEASES OF THE RESPIRATORY ORGANS. 



and then, by overcoming the cause, you may relieve the paroxysm 
at once. If you are unable to remove the cause, or the paroxysm 
is not reUeved, place the patient in the easiest position possible. 
The best remedies to use in this disease are stramonium, in the 
form of cigarettes ; chloroform ; hyoscyamus ; ergot ; ether ; canna- 
bis indica, opium or atropine; and the fumes of burning nitre 
paper. 

Loomis advises opium, hi full doses gr. morph. sulph. hypo- 
dermically); but very good results have been obtained with the 
prescriptions which will be found at the end of this volume, and 
should be tried, especially hyoscyamus and ergot for the first two or 
three days; if they have not the effect of relie\ing it for some con- 
siderable time, the other remedies might be resoited to. Should 
there be anaemia, or the patient be poorly nourished, ol. morrhuce 
and iron should be administered at intervals. Quinine, gr. v.-x, 
daily, often prevents the paroxysms, and it must be continued 
regularly, or else the paroxysms will return. 

whoopingT cough. 

SYNONYM. 

Pertussis. 

DEFINITION. 

It is an infectious and portable disease, dependent upon a Specific 
poison ; characterized by a paroxysmal cough, consisting of a 
series of short, spasmodic, forcible expirations, followed by a deep, 
prolonged inspiration, attended with a peculiar sonorous sound 
called the "whoop" or "kink," the paroxysms terminating in 
expectoration or vomiting. 

MORBID ANATOMY. 
The principal changes are those of catarrhal bronchitis. It is 
considered by many prominent physicians to be of nervous origin; 
and that either an inflammation of the pneumogastric nerve or 
congestion of the medulla oblongata exists. The complications 
are lobular collapse, lobular emphysema, bronchial dilatation, and 
catarrhal pneumonia. 



WHOOPING COUGH. 



59 



- STAGES. 

It has three stages, catarrhal, spasmodic, and decline. 

SYMPTOMS. 
Rational. 

In the Catarrhal Stage. 

Marked naso-pharyngeal and bronchial catarrh. 
Coryza. 

Cough — paroxysmal in character. 

Expectoration — abundant, (tenacious, viscid, transparent 

mucus). 
In the Spasmodic Stage. 

Cough — severe and distressing, there is at first a long, clear, 

piping, inspiratory sound ; followed by convulsive and 

forcible expiratory puffs and succeeded by a whoop. 
Face — becomes red or purplish during the paroxysm. 
Eyes — protrude during paroxysm. 
Vomiting may follow paroxysm. 
Bleeding from nose, mouth, and ear may occur. 
In the Stage of Decline. 

Paroxysms gradually diminish in frequency and severity. 
Expectoration is less difficult (becomes more purulent, and, 

after a while, ceases altogether). 

Physical. 

Auscultation — during the paroxysm, the respiratory murmur is 
feeble or absent. Sibilant and sonorous rales (which during 
the interval are mucous in character). 

DIFFERENTIAL DIAGNOSIS. 
In the early stages, its diagnosis is uncertain ; but if there is a 
violent spasmodic cough, the fever excessive and prolonged, and 
the disease is prevalent, its existence may be suspected. Its pecu- 
liar cough distinguishes it from all other diseases. 

PROGNOSIS. 

Is always a serious disease, although rarely directly fatal ; but 



60 



DISEASES OF THE RESPIRATORY ORGANS. 



it frequently causes death indirectly. Fatal results are due to 
complications. t 

TREATMENT. 

In order to relieve the paroxysms of coughing, the most effec- 
tive remedies are belladonna, hyoscyainus, cannabis indica, chloro- 
form, and musk, which should be administered in small doses. 
The patient should guard ag^st undue exposure ; his clothing 
should be warm. During fine, warm weather, the patient should 
be in the open air as much as possible ; but damp, cold weather, 
and exposm-e to draughts must be strictly avoided. The diet 
should be simple, and the bowels carefully attended to. In 
obstinate cases and in convalescence, a change of air, if only for a 
short distance, often proves very beneficial. If possible, moun- 
tain, or sea air, or pure country au', should be chosen, as it acts 
favorably by removing irritation of the nervous system, and com- 
pleting restoration to health. 

E^IPHYSEMA. 
DEFINITION. 

Is an abnormal accumulation of air within the air-ceUs ; or an 
infiltration of air into the sub-pleural cavity, or interstitial con- 
nective-tissue, due to rupture of the air vesicles. 

YARIETIES. 

Vesicular — ^where the air-cells alone are over-distended and con- 
tain an excess of air. 

Interlobular or interstitial — where the air has escaped between the 
lobules of the lung (through rupture of the air-cells). 

MORBID ANATOMY. 

Before opening the body you will notice the ''barrel-shaped'' 
chest, emaciation, and the emi3hysematous countenance. 

On opening the chest, the lungs fail to collapse, and, in bad 
cases, protrude from the chest ; they frequently bear the impres- 
sion of the ribs, and have blebs on the surface (due to an inter- 
stitial emphysema). 



EMPHYSEMA. 



61 



The specific gravity of the lung is greatly diminished ; they are 
paler in color than normal, and crepitate less than normal. The 
bronchi are partially filled with sticky mucus, and spaces may be 
seen, by the eye (when a section is made), in the lung substance, 
due to breaking down of the air-cells, thus allowing of a communi- 
cation with each other. The heart will be found displaced, and 
the right heart is usually hypertrophied. Tricuspid regurgitation 
is not infrequent. Thea^e is often found the " nutmeg''' liver, and 
the other organs may Be in a state of fatty degenel'ation. 

When one of the lungs is removed, inflated, injected through 
the pulmonary and bronchial vessels, and dried, a section will 
show (1st) abnormal spaces due to rupture of the air vesicles ; (2d) 
obliteration of the blood-vessels in the septa between the air-cells; 
(3d) destruction of the septa between the air-cells, due to fatty 
degeneration, from poor nutrition, on account of destruction of 
the blood-vessels. ■ 

- ETIOLOGY. 
Primary Causes* - » 

Forced inspiratory and expiratory efforts. — Severe coughing 
or straining.— 4Iereditary, or acquired impairment of the 
elasticity of the liing tissue.- — Abnormal growth of the chest- 
walls. 

Secondary or Compensator^ Causes. 

Emphysema of the-immediate liing tissue, around small por- 
tions of the lung, rendered inexpansible from disease. 

Vicarious Emphysema. 

Emphysema, of the liealthj lung, may be produced where 
large portions of the lung tissue are consolidated, or impaired 
by disease, as in atelectasis, from obstruction of a small bron- 
chus, a lobai' pneumonia, or pulmonary infarction. 
Interlobular emphysema may follow the vesicular form (by 

rupture), or perforation of the lung tissue (from traumatism, 

foreign bodies, etc.). 

SYMPTOMS. 
Eational. 

Dyspnoea. 

Increased by exercise. — Increased by attacks of bronchitis. — 
Increased by attacks of asthma. — Increased by cold climate. 



62 



DISEASES OF THE RESPIRATORY ORGANS. 



Expectoration. 

Of a pearly, tenacious mucous (due to an accompanying 
bronchitis). 
Countenance. 

Dusky — Puffy, even where the body is emaciated, — The nos- 
trils are distended, and vascular, and expand with inspiration. 
— Angles of mouth are drawn down. — Jugular veins are dis- 
tended. 
General Condition. 

Feeble voice. — Emaciation. — Stooping attitude in walking — 
Gradual loss of strength. — Low temperature. — Feeble pulse. — 
Vertigo, after coughing. — CEdema of feet and ankles (in late 
stage) due to tricuspid regurgitation. — Exhausting cough. 
Physical. 

Inspection Reveals 

Prominence of the sternum. — Widening of the intercostal 
spaces.— Round or "barrel shaped'' chest. — No actual ex- 
pansion, but a rising and falling movement of the sternum 
during respiration. — Displacement of the apex-beat. — Abdo- 
minal breathing. — Muscles of the neck very prominent. 

Palj)atio7i. 

Variable — vocal fremitus is usually diminished, except in the 

senile form, when it is increased. 
Rercussion . 

Vesiculo-tympanitic (due to too much air). 
Asucidtatoon. 

Inspiratory sound, is feeble, or suppressed. — Prolonged, low- 
pitched, expiratory sound (due to loss of elasticity of the lung- 
tissue). — Crackling sound like the crumpling of parchment. 

DIFFERENTIAL DIAGNOSIS. 
From pneumo-thorax only. 

COMPLICATIONS. 
Heart disease, (chiefly of the right heai't) ; bronchitis (acute 
attacks). 

Fatty degeneration of the organs throughout the body, and dis- 



PULMONARY CEDEMA. 63 

ease of the kidney, or liver (due to the interference of the 
general circulation). 

PROGNOSIS. 

It is an incurable disease ; is modified by the extent of the dis- 
ease, and by its complications; the most frequent being bronchitis, 
which is always an extremely grave affection, when the smaller 
tubes are attacked. 

TREATMENT. 

Iron should be given daily with the meals for a long period, in 
the form of the ethereal tincture of the acetate ; and, also sulphate 
of quinine in small doses with the iron. If there should be 
dyspeptic symptoms, bitter vegetable infusions should be given ; 
and oleum morrhuce, for the emaciation that is present. Stimu- 
lants are often of great benefit when taken in small quantities 
during, or shortly after meals. The diet should be most nutri- 
tious ; principally animal food. The stomach should not be over- 
laden. The food should not be bulky or watery in character, but 
as digestible as possible. Small quantity of liquids should be 
used at a time. The patient should live in the open air, but not 
expose himself to cold ; and all violent exercise should be avoided. 
The complications should be treated as they arise ; but the most 
persistent is bronchitis, and, when this occurs, iodide of potassium 
should be administered, in gr. v.-xx., three times a day, and con- 
tinued for a long period. The other complications will be treated 
under their respective headings. 

PULMONARY (EDEMA. 
DEFINITION. 

Is a serous transudation from the pulmonary blood-vessels, de- 
pendent either upon some local cause, or an altered state of the 
blood. 

MORBID ANATOMY. 
Serum will be found in the cavity of the alveoli, and the inter- 
stitial-tissue of the lungs. If the oedema be associated with co .i- 
gestion, the serum will be blood-stained; otherwise it will be of a 



64 



DISEASES OF THE RESPIRATORY ORGANS. 



clear color. On opening the thorax, the lungs do not collapse. 
That part of the lung where the oedema is present will be paler 
than normal, unless congestion be present. In the oedematous 
portion of the lung, 4f it pit on pressure, it proves that the elas- 
ticity of tiie lung has been diminished. On section , serum exudes; 
which is usually frothy, unless the air-cells are filled with seram. 
CEdema may occur in any "portion of the lung, but it is usually in 
the most dependent part. 

In order to determine whether the oedema has occurred before 
or after death, it will be necessary to know what the physical 
signs and symptoms were before death took place. 

ETIOLOGY. 

General hydrsemia (as in purpura. Brighfs disease, scurvy, etc.). 
Pulmonaiy congestion (dependent upon obstructed return circula- 
tion through the heart). 
Enfeebled heart's action (chiefly in the aged). 

Lougwcoiifinement;to;on,e position (as in fevers, debility, etc.), be- 
cause the blood g^^v^iys* goes to the most dependent part of the 
body. 

Inflammatory conditions of the lung tissue (as in pneumonia, 
tuberculosis, capiUary bronchitis), due to passive hypereemia 
or stasis. 

SYMPTOMS. 
Rational. 

Dyspnoea— is often sudden and severe. 
Respiration— is increased in frequency. 
Cough. 

Expectoration — watery, and slightly blood-stained (if pulmonarv 
congestion exist). 

Temperature— normal. 

Pulse — ^if increased In frequency, is feeble. 

Cyanotic Condition {if osdema ?s excessive) as shoivn hy 

Blueness of the face.— Blueness of the extremities. — Coldness 
of the limbs. — Delirium. — Drowsiness. — Coma. 

Physical. 

Percussion— there is dullness over the seat of the oedema which is 



PULMONARY CEDEMA. 



65 



usually at the most dependent portion of the lung. This dull- 
ness never reaches the condition of flatness, nor changes posi- 
tion. 

Auscultation — bubbling rales over the seat of the oedema, heard 
with inspiration and the commencement of expiration. These 
rales have a liquid character, and are thus to be distinguished 
from the crepitant rale. Eespiratory murmur is feeble, or 
absent, or harsh. 

DIFFERENTIAL DIAGNOSIS. 
From pneumonia (1st stage) — hydro-thorax — capillary bron- 
chitis — and pulmonary congestion. 

PROGNOSIS. 

Is bad, if it depend ui^on the general dropsy of renal or cardiac 
diseases. 

Is bad, if complicating an extensive pneumonia. 
Is bad, if extreme cyanotic symptoms appear. 
Is bad, if dependent on exhaustive diseases. 

TREATMENT. 

If it occur in connection vrith Bright's disease, increase the ex- 
cretory fmictions of the kidneys, bowels, and skin with hydra- 
gogue cathartics, diuretics, and diaphoretics, and crowd them to 
the fullest extent. 

Apply dry cups to the thorax. Stimulants should be given, if 
it occur in connection with typhoid and typus fever. Any means 
which will relieve or arrest the congestion are of benefit. 

If the oedema be due to the patient remaining too long in one 
position, then move him coubtantly to prevent the gravitation of 
the fluid to the same dependent part; and endeavor to have the 
lungs emptied as frequently and fully as possible. 

PULMONAEY CONGESTION. 
DEFINITION. 
Is an excess of blood in the circulation of the lung. 



DISEASES OF THE RESPIRATORY ORGANS. 



Varieties. 

Active Hypercemia, 

Active — associated with dilated capillaries, increased flow of 
blood to the part, and an increased rapidity of the current. 

Passive Hypercemia. 

Passive, or "congestion'' — associated with dilated capillaries, 
increased flow of blood to the part, and a slow current. 

Hypostatic congestion— is that form of pulmonary .congestion 
which is due to gravitation, and associated with intra-cellular 
oedema. 

Compensatory or collateral congestion — is that form of pulmonary 
congestion which is due to obstruction in some other part of 
the lung. 

Splenization of tiie lung —is that form of pulmonary congestion, 
which may be superficial or central; is associated with 
interstitial oedema, with red or yellow spots throughout the 
lung; and which resembles the spleen in appearance. 

Brown induration of the lung — is that form of^'pulmonary conges- 
tion which is characterized by pigmentation; as a result of 
chronic passive hyperasmia, from mitral obstruction or regur- 
gitation. 

MORBID ANATOMY. 

"When the condition constitutes hypergemia, the lungs are dis- 
tended, of a dark-red color, slightly crepitating, and heavier and 
less elastic than normal. On section, dark blood flows freely from 
the cut surface; but the lung-tissue is still of a dark color, due to 
blood remaining in the capillary vessels. 

Pulmonary hypera^mia may be active or passive, it is simply 
an increased quantity of blood in the capillaries, and may be due 
to increased heart's action, or obstruction to the return of blood to 
the heart, or local interference with the pulmonary circulation^ 
The various conditions wliich the lung may assume are as follows: 

Splenization. — In this condition the lung is of a dark reddish- 
blue, brown, or black color, airless, firmer than normal, and cre- 
pitates imperfectly. On section, a dark fluid oozes from its sur- 
face, but not so freely as in hypereemia. 



PULMONARY CONGESTION. 



67 



Hypostatic congestion. —This occurs in persons suffering from 
diseases which confine them to their bed for a long time. This 
form closely resembles splenization, but has neither the doughy 
feel, nor the whitish or reddish points. 

Compensatory Congestion. — This is due to obstructed pulmonary 
circulation, (as in pneumonia) and occurs also in collapsed lung- 
tissue. % 

Brown induration. — This is epecially connected with mitral 
obstruction, or regurgitation. The lung will be found to be dis- 
tended, firm, heavy, slightly moist, and dotted over with yellow- 
ish or brownish spots; these spots are due to old blood extravasa- 
tions which have undergone granular pigmentary degeneration. 
The capillaries are enlarged. Under the microscope, the air-cells 
are found to contain large cells which have undergone more or 
less pigmentation. 

ETIOLOGY. 

Causes of Active Hypercemia. 

Violent heart's action. — Accelerated heart's action. — Exces- 
sive exercise, especially in those whose chest is small. — In- 
halation of too stimulating air. — Too rarefied air. 

Causes of Passive Hypercemia. 

Feeble heart's action (due to obstruction to the return circu- 
lation of the lungs).— Mitral disease. — Pressure on the pulmon- 
ary veins. — Fluid in the pleura, aneurism, cancer, tumors, 
collapsed lung (by impeding the venous return from the 
lungs). 

Hypostatic Congestion. 

Is dependent on gravitation, and occurs in those who have 
been long confined to one position. — Is associated with intra- 
celhUar oedema of the lung. 

Compensatory Congestion. 

Is the result of obstruction in the circulation in some other 
part of the lung. Occurs in connection with pneumonia, 
mediastinal tumors, and collapsed lung. 

Splenization. 

Lung resembles spleen-tissue. — Is due to hyperaemia, with 
interstitial oedema superadded. — Occurs chiefly in connection 
with typhoid and typhus fever. Is of slow development. 



68 



DISEA.SES OF THE RESPIRATORY ORGANS. 



Brown Induration. 

Is a pigmented condition of the lung, due to obstruction or 
regurgitation at the mitral valve. 

SYMPTOMS. 

RATIONAL. 

Dyspnoea, (very marked if pulmonary oedema exist;. 
Cough. 

Expectoration (blood-stained and watery). 
Symptoms of impaired function of lung-tissue. 

Physical. 

PaZpah'on.— Increased vocal fremitus. 

Percussion. — Dull over the seat of the disease (on occount of 
oedema). 

Auscultation. — Respiration feeble, or harsh; liquid rales, if oedema 
exist. 

DIFFERENTIAL DIAGNOSIS. 

From pulmonary cedema; spasmodic asthma; first stage of 
pneumonia; and capillary bronchitis. 

PROGNOSIS. 

In_ active hypercemia — of a rapid type; terminates either in re- 
covery, pneumonia, or pulmonary hemorrhage. 

In passive liypercemia — depends upon the complications; espe- 
cially heart-diseases. 

In brown induration — the prognosis is uncertain. 

In splenization — the results are unfavorable. 

TREATMENT. 

When the congestion is active and comes on suddenly, the 
quantity of blood in the vessels must be lessened. Wet or dry 
cups should then be applied over the entire chest, or, by opening 
of the vein in the arm, the general system may be depleted. 
In passive congestion, the pulmonary circulation must be regu- 
lated. If the heart's action be weak, stimulants must be resorted 



PULMONARY APOPLEXY. 



69 



to, but should the heart's action be too forcible, give aconite in 
full doses. If it be associated with pulmonary oedema, administer 
cathartics. 

PULMONARY APOPLEXY. 
VARIETIES. 

Circumscribed, or "pulmonary infarction," when the lung tissue 
is not lacerated. 

Diffused, or "pulmonary apoplexy," when the parenchyma of 
the lung is lacerated. 

MORBID ANATOMY. 

In the circumscribed variety, the lungs contain hemorrhagic 
nodular infarctions, which may be of a dark-red, or black color, 
containing no air. These infarctions may be hard or soft, according 
to their age, and are recognized by their firmness when pressure is 
made. They may be from one to four inches only, but are usually 
about one inch in diameter. They are found most frequently in 
the posterior portion of the lower lobe of the lung. These nodules 
are, as a rule, formed by the escape of blood from the capillaries 
of the air-cells into the cavity of the alveoli, and minute bronchi, 
some of which is retained in these cavities as the blood coagulates; 
the capillaries around the alveoli are found to be filled with 
blood, but there is no rupture of the lung-tissue. Resolution is 
the most frequent change that occurs; the infarction becoming 
either absorbed or expectorated. 

As a second result, these infarctions may remain as dark 
pigmented, cicatricial spots, impermeable to air; they may excite 
inflammation of a pneumonic character, which may terminate in 
gangrene; or the nodules may become gangrenous. 

If the infarctions occur in connection with pyfBmia, they may 
terminate in gangrene, or in the formation of abscess. 

If the infarctions be near the surface, the pleura may be 
lacerated. In case the diffuse variety exists, the cavity made in 
the lung tissue by the extravasation is of considerable size, and 
the coagulated blood resembles a blood-clot. These extravasations 
are diffused and are much larger than the circumscribed variety. 



70 



DISEASES OF THE RESPIRATORY ORGANS. 



They may prove fatal at once, if the pleura be perforated. If the 
patient survive the shock, recovery usually takes place ; either 
by adhesion of the torn surfaces, or a connective-tissue capsule 
being formed around the clot, which undergoes a cheesy, chalky, 
or pigme:!ited degeneration, and remains imbedded in the lun£- 
tissue. 

ETIOLOGY. 

Causes of the Circumscribed Form. 

Embolism (due to vegetation of the valve of the right heart). 

— Coagula from the right heart or some superficial vein. — 

Pyaemia (metastatic). — Phthisis. — Cholera. — Scurvy. 
Causes of the Diffuse Form. 

Aneurism. — Degeneration of the arterial coats. — Traumatism. 

SYMPTOMS. 
Rational. 
Dyspnoea — if the apoplexy be extensive. 
Sense of constriction in the chest. 
Pain — if the pleura be affected. 
Expectoration — of small blood-coagula. 

Ifpycemic in origin, the attack is accompanied by a chill and a 
marked rise in temperature. 

Physical. 

Percussion — local dullness over the seat of the disease. 
Auscultation — respiratory murmur may be absent, if the air-cells 

are extensively involved. 
Bronchial breathing is often detected over the seat of the disease. 

DIFFERENTIAL DIAGNOSIS. 
From pulmonary congestion; pulmonary oedema; and bronchial 
hemorrhage. 

PROGNOSIS. 

Is good, in the case of infarction, if not too extensive, and not 
dependent upon pyaemia or in connection with thrombosis. 

Is bad, in the diffused form, unless sliglit in amount and of 
traumatic origin. 



BRONCHIAL HEMORRHAGE. 



71 



TREATMENT. 

The patient must be kept in bed, and. perfectly quiet. Stimulat- 
ing applications, such as mustard sinapisms, must be applied to 
the extremities, and dry cupping to the chest-surface. Should it 
result from heart disease, regulate the heart's action, and increase 
its force by moderate use of stimulants and full doses of digitalis. 
If it occur with pyaemia, support your patient to the utmost, by 
giving stimulants, quinine, and iro7i, and apply dry cups over 
the chest-surface frequently. The diffuse variety is not amenable 
to treatment. 

BRONCHIAL HEMORRHAGE. 
DEiTOITIO^. 

Is a hemorrhage of the brc n hial mucous membrane, and not of 
the parenchyma of the lung, 

MORBID ANATOMY. 
The bronchial mucous membrane, at the seat of hemorrhage, 
will be found to be swollen, relaxed, and bleeds on slight pres- 
sure. It is uniformly dark-red in color, with spots of ecchy- 
mosis, provided the examination be made soon after, or at the 
time of a hemorrhage. But should t]i3 examination be made sonie 
time after the bleeding, the bronchial mucous membrane will be 
pale, and bloodless in appearance, or, the seat of the hemorrhage 
will not be able to be discovered. If any of the small bronchi are 
occluded by blood-clots, the lung-tissue beyond the seat of the 
plugs will remain inflated after the thoracic cavity is opened. 

ETIOLOGY. 
Predisposing Causes. 
.Previously weak pulmonary capillaries are often a predisposing 
cause, as occurs : 

In delicate persons of phthisical parentage. — In developed 
phthisis or a phthisical diathesis. — In chronic bronchial 
catarrh, which tends to weaken the vessels. 

Exciting Causes. 
Excessive exertion. — Atmospheric conditions. — Inhalation of irri- 
tant gases, etc. — Excessive rarefaction of air. 



73 



DISEASES OF THE RESPIRATORY ORGANS. 



SYIklPTOMS. 
Eatioxal. 

Expectoration — is of bright arterial blood, with a frothy appear- 
ance. 

Previous sense of constriction in the chest. 
Cough and frequent return of hemorrhage. 
Pallor and anxietj^ of face. 
Tremulousness. 
Syncope —is possible. 

Nausea and vomiting — may follo' : the hemorrhage, but never pre- 
cede it. 

Symptoms of a subsequent pnemno" ia or phthisis may develop. 
Physic iL. 

Ausmltation — large and small bronchial rales, over the seat of 
hemorrhage, may be detected. 

DIFFEEENTIAL DIAGNOSIS. 
From gastric hemorrhage, thoracic aneurism, epistaxis, and 
pulmonaiy apoplexy. 

PROGNOSIS. 

Is seldom fatal, even in severe attacks, unless associated with 
some other disease. It is either the precm'sor of phthisical de- 
velopment, or a sign that phthisis exists. 

TREATMENT. 

The patient should be placed in bed, and kept absolutely quiet; 
not even being allowed to sit up, or move, or speak above a 
whisper. The room should- be cool. Opium should be given in 
full doses, if the cough be constant and produce hemorrhage. In 
order to quiet the anxiety of the patient or friends, ergot, sjjirits 
of turpentine, persulphate of iron, or chloride of sodium may be 
given. Ice bags may be applied, but great care should be used in 
applying them, as broncho-pneumonia is apt to follow such attacks 
of hemorrhage. Ice should be eaten, and cold iced-water drank 
freely. The nutrition of the patient should be improved by iron, 
ahd a very nutritious but not stimulating diet. Avoid all mental 



PULMONARY GANGRENE. 



73 



and physical exercise, but the patient should spend some hours 
daily in the fresh air. 

PULMONAKY GANGEENE. 
DEFINITION. 

A death of lung-tissue in mass— as contrasted with molecular 
death. 

VARIETIES. 

Circumscribed — ^where only small localized spots are affected. 
Diffused — where extensive portions of the lung-tissue are involved. 

MORBID ANATOMY. 
In the circumscribed form, it usually occurs in the lower lobes 
or on the surface of the lungs. Small portions of the lung become 
converted into sloughs, which may be discharged through a 
bronchus and leave a ragged cavity surrounded by inflamed lung- 
tissue. 

An opening is sometimes found in the pleural cavity, causing 
acute pleurisy, or hydro-pneumo-thorax. 

In the diffused form, an entire lobe may be involved or even the 
entire lung; the gangrenous processes are not limited, but may 
become oedematous, or hepatized lung-tissue may be found. It 
may become converted into a putrid mass, and as the gangrenous 
process reaches the pleura, that membrane becomes destroyed, and 
the patient dies of pyaemia or septicaemia. 

ETIOLOGY. 

It may occur from: 
Local Causes. 

Pneumonia. — Hydatids.— Infarction (hemorrhagic). — Cancer. 
— Bronchial dilatations. — Embolism of an artery. 
Nervous Diseases. 

De mentia. — Cerebral softening. — Epilepsy. — Chronic alcohol- 
ism. 

Blood- Poisoning. 

Pyaemia.— Septicaemia. — Glanders. — Fevers. 



74 



DISEASES OF THE RESPIRATORY ORGANS. 



SYMPTOMS. 
Rational. 

Marked fetor to the breath. 

Expectoration — of a gangrenous material, or black lumps of lung- 
tissue. 

Hemorrhage — in some cases. 

Great physical prostration— (if septic poisoning occur). 

Physical. 

These are often obscure, and comprise those of consolidation, and, 

possibly, the existence of a cavity, viz. : 
Percussion — localized dullness. 

Auscultation — bronchial respiration; amphoric or cavernous 
breathing; and, possibly, gurgling. 

DIFFERENTIAL DIAGNOSIS. 
From abscess of the lung; phthisis; and foetid bronchitis. 

TREATMENT. 

Sustain the patient with stimulants, tonics, and a most nutri- 
tious diet. Give opium to relieve pain, allay the cough,' and :^^er- 
come constitutional irritation . 

CANCER OF THE LUNGS. 
VARIETIES. 

Medullary (as the rule); and melanotic, in rare cases. This dis- 
ease may also be unilateral; or diffused, as nodules, throughout 
both lungs. 

MORBID ANATOMY. 
The meduUary cancer is the only one met with in this disease, 
as a rule. Primary cancer only affects one lung, while the 
secondary form usually affects both. Jt occurs in the form of 
nodules scattered through the lung-substance. The nodules may 
blend and involve the entire lung. The cancerous matter may 
undergo fatty degeneration, and soften ng; it may also involve 
the pulmonary vessels and bronchi, or cause obliteration of them 



CANCER OF THE LUNGS. 



75 



through pressure. There are usually extensive pleuritic thicken- 
ings and adhesions present. 

ETIOLOGY. . 

Predisposing Causes. 

Hereditary tendency. — Is most common in the male sex, and 

occurs between 40 and 60 years of age. 
Exciting Causes. 

Cancer in the breast in females. — Injury. — Previous disease. 

SYMPTOMS. 

Rational. 

Pain — in the chest. 
Cough. 

Expectoration — often like ''currant jelly." 

Dyspnoea— most marked when the mediastina are affected. 

Emaciation and oedema of the face. 

Te mperature — elevated . 

Night-sweats and exhaustion. 

Hemorrhage — severe in some cases. 

Cyanosis. 

Vertigo. 

Swollen jugulars. 

Cachexia. — (may exist in some cases). 

Physical. 

Inspection — enlargement of the affected side, if the disease be ex- 
tensively developed. Diminished respiratoiy movements. 

Palpation — diminution, or absence of vocal fremitus. 

Percussion — marked dullness over the seat of the disease with 
spots of resonance. 

Auscultation — feeble or absent respiratory sounds. Bronchial 
breathing (if the cancer and a large bronchus be intimately 
connected). 

DIFFERENTIAL DIAGNOSIS. 
From pleurisy with serous effusion; gangrene of the lung; 
aneurism of the aorta; phthisis; or fibrous pneumonia. 



76 



DISEASES OF THE RESPIRATORY ORGANS. 



PROGNOSIS. 

Always fatal. Death may occur from exhaustion; hemorrhage; 
pulmonary oedema ; asphyxia ; or pressure on the oesophagus, 
trachea, or thoracic duct. 

TREATMENT. 

Is altogether palliative. The symptoms must be relieved as 
they arise. 

PNEUMONIA. 
DEFINITION. 

Is an inflammation of the air-cells and intercellular passages — 
or, of the parenchyma of the lung. 

VARIETIES. 

Croupous or "lobar" — where a distinct lobe is affected. 
Catarrhal or * ' lobular " or " broncho-pneumonia " — where a lobule 

is affected in different parts of the lung. 
Fibrous or " interstitial" or " pulmonar}^ cirrhosis " — where new 

connective-tissue development is the principal pathological 

change. 

CROUPOUS PNEUMONIA (Lobae). 

STAGES. 

First, engorgement; second, red hepatization; third, gray hepa- 
tization. 

MORBID ANATOMY. 
I7i the first stage — the lung in the affected part is redder, and 
crepitates less than normal. The specific gravity is increased. 
The lung is firmer on pressure than normal. On section, you wiU 
' perceive a reddish fluid, partly serous and partly blood, to exude 
from the cut surface. The microscope will show a congestion of 
the capillaries of the waUs of the air-cells. 

I7i the second stage — the affected lobe will be solid to the touch, 
and all crepitation absent It pits on pressure and becomes 



CROUPOUS PNEUMONIA. 



77 



friable, and is of a dark -brown or reddish color; is heavier than 
normal, and sinks in water. On section, it will be granular (due 
to filling up of the cells with pneumonic material), giving it an 
appearance similiar to liver-tissue. About twelve hours after 
death, you get the post-mortem fluid, which, under the micro- 
scope, will be found to consist of fibrillated fibrin, blood-globules, 
lymphoid cells and large nucleated cells. The lung-substance will 
have lost the outline of the air-cells, if viewed microscopically. 

In the third stage— the lung will be found mottled with dark 
spots, becoming uniformly gray (due to decoloration of melanine). 
On squeezing, it will now begin to crepitate, and has lost its solid- 
ity. The specific gravity is nearly normal, and the lung will 
sometimes float in water. On section and squeezing the lung, a 
milky or purulent fluid will be obtained. 

Microscope. — The outline of the cell wall will be seen (from loos- 
ening and separation of the inflammatory material) ; and a granu- 
lar substance in the centre of the cell will be perceived (which is 
a degeneration of the fibrin and the other inflammatory products). 
The blood-vessels will appear normal, and the epithelial lining 
will probably be intact. 

ETIOLOGY, 

Predisposing Causes. 

Age (most common between 20 and 40). — Sudden change in 
temperature.— Poverty. — Intemperance. — Previous attacks. 

Exciting Causes. 

Exposure to cold or wet (as chilling of the feet or body). — 
Special diseases (^s exanthematous fevers, uraemia, pyaemia, 
septicaemia, alcoholism, etc ). — Traumatism. 

SYMPTOMS. 
Rational. 

Chill — usually severe, prolonged, and distinct. 
Headache, or vomiting, or bronchial hemorrhage. 
Convulsions — (in children). 
Coma— (in the aged). 

Pain — (in the affected side for about three days). 



78 



DISEASES OF THE RESPIRATORY ORGANS. 



Cough — (a constant symptom). 

Expectoration— scanty, pinkish, and viscid (at onset); (later on), 
brick-dust, and tenacious; (severe case) resembling prune juice. 

Temperature — elevated (highest on the third day, 102°-105). 

Eespiration— increased (80 per minute), panting in character. 

Pulse — elevated (90 to 120)— is intermittent, in old age. 

Countenance— anxious; flushed spot on the cheek; mahogany 
color (in severe cases). 

Delirium — (in alcoholismus). 

Urine — scanty, high-colored, high specilic gravity, and albumin- 
ous. 

Physical. 

Stage of Engorgement. 

Inspection — slight impairment of motion on the affected side. 
Palpation — slight increase of vocal fremitus. 
Percussion — slight dullness. 

Auscultation — crepitant rale, (at the end of inspiration). 
In Red Hepatization. 

Inspection — marked impairment of motion on the affected 

side, and increased motion on the healthy side. 
Palpation — marked increase' of vocal fremitus. 
Percussion — marked dullness. 

Auscultation— bronchial respiration; bronchophony; increased 

intensity of vocal sounds. 
In Gray Hepatization. 

Inspection — partial return of motion on the affected side. 
Palpation — slight increase of vocal fremitus and resonance 

over normal standard. 
Percussion — decrease in dullness. 

Auscultation — rude respiration or "broncho-vesicular;" rdle 
redux, or modified subcrepitant, and crepitant. 

DIFFERENTIAL DIAGNOSIS. 

From cerebral disease, and cerebro-spinal meningitis (in chil- 
dren); from pleurisy in all its forms; phthisis (second stage); from 
capillary bronchitis ; pulmonary oedema, and abscess of the liver 



CROUPOUS PNEUMONIA. 



79 



PROGNOSIS. 

Is bad in infancy; old age; chronic alcoholism; in complications 
(as Bright's, heart, pregnancy); when very high temperatm'c 
exists; if the pulse be over 150; in case of delirium after first week: 
if pulmonary oedema be present or double pneumonia, also when 
jaundice and prune-juice expectoration exist. 

CAUSES OF DEATH. 

Heart's failure and heart-clot; pulmonary oedema; asphyxia; 
and exhaustion. 

TREATMENT. 

Bear in mind the constitutional condition of the patient and 
trust Nature to help you. Blood-letting is only to be resorted to if 
the heart is engorged, and pulmonary congestion and oedema 
seem likely to take place. Digitalis or mix vomica should be 
given as a heart-tonic. Keep the patient in bed in a large, well- 
ventilated room, with a temperature about 68° to 70% and give 
good nourishment (as milk, eggs, etc.). 

Inject morphine hypodermically, if there is pain. Give opium 
or chloral, in small doses, should there be vomiting. 

The dangers of this disease, in delicate subjects, are high tem- 
perature and feeble heart-power; it will therefore be advisable to 
reduce the temperature by giving sulphate of quinine, gr. xx.- 
XXX. per diem, and sustain the heart-power with alcoholic stimu- 
lants (judiciously applied — that is, just sufficient to tide the heart 
over the crisis). 

If the pulse be rapid and feeble (120 to 130 per minute), stimu- 
lants should be given in small doses, not exceseding six to eight 
ounces in the twenty-four hours. Belladonna may be adminis- 
tered if the pupils are contracted. 

Give chloral, in small doses, if the patient be restless and cannot 
sleep. Use champagne as a heart-stimulant. In convalescence, 
give iron, oleum morrhuce, and a good nutritious diet. 



80 



DISEASES OF THE RESPIRATORY ORGANS. 



OATAEEHAL PNEUMONIA (LOBULAE) OE 
BEONCHO-PNEUMONIA. 

DEFINITION. 

The form which affects the scattered lobules and not a lobe of 
lung. Is most extensively developed in the anterior and posterior 
portion of each lung. 

MORBID ANATOMY. 

When the lung is inflated, there are small yellow or red spots 
which do not inflate, and which are not granular on section. If 
these spots be near the surface of the lung, they will be found to 
be rounded masses, and may be mistaken for tubercles. If the 
nodules are large, a reddish or grayish fluid exudes when cut; the 
nodules break down easily, and sink when thrown into water. 

In the SECOND STAGE or " stage of red hepatization," the exuda- 
tion is made up of granular fibrin, blood-globules, lymphoid cells, 
and large nucleated cells. 

In the third stage or "stage of gray hepatization," the nodules 
have a tendency to terminate either in resolution, purulent infil- 
tration, or cheesy degeneration. The small bronchi are filled with 
tenacious mucus or muco-pus ; their walls are thickened; and 
their calibre is enlarged. 

If resolution or purulent infiltration occur, the infiammatory 
products undergo changes similar to those which take place in 
croupous pneumonia. If the products in the alveoli or bronchi 
become cheesy, a hyperplasia of the connective-tissue takes place, 
producing more or less induration (thus corresponding to catarrhal 
phthisis). 

STAGES. 

The same three as in croupous pneumonia, viz.: engorgement; 
red hepatization; and gray hepatization. 



CATARRHAL PNEUMONIA OR BRONCHO-PNSUMONIA. 81 



ETIOLOGY. 

Predisposing Causes. 

Most frequent in children, and follows pulmonary collapse; 

measles; diphtheria; whooping cough; bronchitis; prolonged 

recumbent position; or debility. 
Exciting Causes. 

Inhalation of an impure or irritating atmosphere. 

SYMPTOMS. 

Rational. 

Previous symptoms of a bronchitis. 
Temperature — rising to 104*^ or even higher. 
Pulse and respiration — accelerated. 
Respiration — becomes panting aud rapid. 
Face — flushed and anxious. 
Cough — dry, hacking, and painful. 

Expectoration — scanty ; often absent ; seldom brick-dust in color. 

In Acute Cases. 

Lividity. — Extreme dyspnoea. — Convulsions. — Speedy death. 
In Subacute Form. — (principally in strumous children). 

Cough — severe and ^metallic. — Emaciation marked. — Marked 
pallor of face. — Night-sweats. — Gradual exhaustion.— Absces- 
ses often form on nates and back. 

Physical. 

Percussion — slight dullness, in front and behind, (if pneumonic 

nodules are large). 
Palpation — vocal fremitus slightly increased. 

Auscultation — respiratory sounds feeble (when tne tubes are ob- 
structed); and bronchial in character, within the spots of con- 
solidation. Crackling rales, of a fine and metallic quality, 
may often be detected after violent coughing, at the end of 
inspiration. 

DIFFERENTIAL DIAGNOSIS. 

From capillary bronchitis; collapse of the lung; croupous pneu- 
monia; and acute tuberculosis. 



83 



DISEASES OF THE RESPIRATORY ORGANS. 



PROGNOSIS. 

Is bad, if secondary to scarlet fever, kidney disease, or infarction. 
Also bad, if developed in the weak; or if the temperature exceed 
105*^; or if due to pysemia. or bad hygienic surroundings. 

TREATMENT. 

The patient should be kept in bed, in a large, well-ventilated 
room with a temperature about 65° to 70°, and the chest protected 
with flannel. Avoid all antiphlogistic measures or depressing 
remedies. Stimulants should be given fro7n the onset, and con- 
tinued to the end of the disease. Dry cupping should be the only 
counter-irritant used. QLiinine should be administered (from gr. 
x.-xx. may be given daily to a child of three years of age). In 
convalescence, give iron, oleum morrhuce, and good nutritious 
food. Avoid fatigue and exposure, and insist upon change of air. 

FIBEOUS PNEUMONIA. 
SYNONYMS. 
Interstitial, or " pulmonary cirrhosis." 

DEFINITION. ' 

Is that form of pneumonia associated with connective-tissue 
growth, and its subsequent organization and contraction. Is 
commonly called ' ' chronic pneumonia. " 

MORBID ANATOMY. 

There is, at first, a hypersemia and swelling of the intercellular 
and interlobular tissue; followed by^ a rapid hyperplasia of the 
connective-tissue, which contracts, and therefore diniiinshes the 
size of the lungs. The chest-walls contract, in consequence of the 
diminution in the size of the lung; and the bronchi become dilated, 
owing to weakness and loss of their elastic power. 

ETIOLOGY. 

The predisposing causes are: encapsulated infarction; encapsu- 



FIBROUS PNEUMONIA. 



83 



lated abscess; acute pneumonia; and splenization. It may occur 
as a result of phthisis. 

SYMPTOMS. 
Rational. 

Retraction of the chest-wall over the affected lung. 

Pain — in the affected side. 

Cough. 

Expectoration — profuse — if the bronchi are dilated — is often foetid 

and contains cheesy matterc 
Dyspnoea — not severe, although constant. 
Emaciation. 
Night-sweats. 
Ansemia. 

Physical. 

InspecHon — retraction of the chest-wall and loss of expansive 
motion. 

Palpation. — the heart is often displaced toward the affected side, 
and signs of hy[3ertrophy of the right side exist, due to ob- 
struction of the pulmonary circulation. 

Percussion — wooden; "cracked-pot resonance," over the dilated 
bronchi may be present. 

Auscultation — feeble and bronchial breathing. Respiration — 
amphoric; or cavernous, if bronchi are dilated. Mucous rales 
— possibly gurgling in character. 

DIFFERENTIAL DIAGNOSIS. 
From pleurisy with effusion; pleurisy with retraction; and can- 
cer of the lung. 

PROGNOSIS. 

Is good, as to duration of life; but bad, if complicated with diar- 
rhoea, hemorrhage, or general dropsy, from either heart or kidney 
lesions. 

TREATMENT. 

This disease, when fully developed, is incurable. If it be due to 
a bronchitis, it is advisable to guard against its recurrence. In 



84 



DISEASES OF THE RESPIRATORY ORGANS. 



order to get rid of the accumulated secretion, and prevent a foetid 
accumulation, inhalation of benzoin or oil of turpentine has been 
recommended. 

PLEUEISY. 
DEFINITION. 

Is a partial or general inflammatory exudation into one or both 
pleural cavities. 

VARIETIES. 

Acute pleurisy — is well defined; runs a rapid course; and has a 

fibrinous exudation. 
Subacute 2^leurisy— is mild; of slow development ; and has a, serous 

exudation. 

Chronic pleurisy, or empyema^' — is of slow development; has a 
sero-purulent exudation; and occurs in persons of debilitated 
constitutions. 

Hydro-pneumo-thorax — is a modification of the chronic form, 
with perforation of the lung, admitting air into the pleural 
cavity (in which fluid also develops, later on). 

ACUTE PLEUEISY. 

MORBID ANATOMY. 

There will be a reddening of the pleural surface, extending to 
the lungs or costal tissues; and, possibly, ecchymosis. New con- 
nective-tissue is formed; with new vessels which have thin walls. 
The pleura will have a thick, swollen, rough, and shaggy appear- 
ance, and have lost its lustre. Its surface may be agglutinated by 
coagulable lymph (fibrin), causing connective-tissue adhesions. 
These adhesions are covered by a layer of pavement epithelium, 
within which run long slender blood-vessels. These adhesions 
may be permanent; or contract, and then undergo fatty degenera- 
tion and absorption, thus producing a simple thickening of the 
pleura. 



ACUTE PLEURISY. 



85 



ETIOLOGY. 

It may occur as a primary or secondary disease, and at any age. 

Primary form may follow 

Exposure to cold or dampness. — Injury. 

Secondary form may he due to 

The different fevers. — Rheumatism. — Bright's disease.— Pyae- 
mia. — Septicaemia. — Alcoholism. —Pneumonia.— Cancer of the 
lung. — Phthisis. 

SYMPTOMS. 
Rational. 

Localized pain — in the side, usually near the nipple. 
Increase of pain on inspiration ; respiration " catching." 
Bending of the trunk toward the affected side. 
Countenance — pale and anxijous may become flushed as the dis- 
ease advances. 
Pulse — increased (90 to 120), flrnis small and tense, 
Temperature — is seldem above l-OO'' — ma;," reach 104*^. 
Cough — hacking ; usually no expectoration is present. 
Thirst. 

Tongue — usually coated. 

Nausea and Vomiting — occasionally present in the early stages. 
Dyspnoea— sudden (if the pleural cavity be over-distended). 
Chills -and, possibly, expectoration of pus (if empyema is de- 
veloped). 

Physical. 

Inspection— re^tvictedi movement of the affected side. 

Palpation — vocal fremitus absent, below the level of the fluid. 

Percussion — dullness, till the fluid accumulates. Flatness below 
the line of the fluid (the line of which changes with the atti- 
tude of the patient). 

Auscultation — friction sounds are heard (before the fluid is 
formed). Vocal sounds are absent, below the level of the 
fluid (after it is exuded). Bronchial breathing, below the level 
of the fluid (in exceptional cases). Return of friction and 
voice sounds (as the fluid is absorbed). 

Retraction of the chest-wall often follows this disease. 



86 



DISEASES OF THE RESPIRATORY ORGANS. 



DIFFERENTIAL DIAGNOSIS. 
From intercostal neuralgia; pneumonia; pulmonary oedema; 
phthisical consolidation; thoracic aneurism. 

PROGNOSIS. 

Is good, if of the primary form; grave, if following any severe 
form of disease, or if absorption be too. long delayed; also if em- 
pyema be developed; or if phthisis be a complication. 

TREATMENT. 

Inject opium, hypodermically, to relieve pain. Patient must be 
kept quiet in bed, in a large, well-ventilated room, at a tempera- 
ture about 65° to 70°, and have good nourishing diet without 
stimulants. 

Give syr. ferri iodidi, 3 i. three or four times daily, if there is 
anaemia. 

SUBACUTE PLEURISY. 
SYNONYM. 

' Sero-fibrous " pleurisy. 

MORBID ANATOIMY. 
There is more extensive connective-tissue formation than in the 
acute form; the j^leura is more thickened and there is more effu- 
sion (serous). The serous fluid in the pleural cavity does not de- 
generate into pus; but an abundant cell-formation takes place. 
The intercostal spaces are distended; the diaphragm is pushed 
down; the viscera are displaced; and the. lung is pushed upward 
and inward against the spinal column (if there is much effusion), 
or compressed (becoming of a pale-red or green color, tough and 
leathery, and containing no air). As the fluid disappears, adhe- 
sions form; the pleura becomes thickened; the chest-walls re- 
tracted; the lungs inexpansible; and the liver may rise higher 
than normal. 

ETIOLOGY. 

The same as in the acute form: it is also secondary to Bright's, 



SUBACUTE PLEURISY. 



87 



phthisis, etc., and occurs in the week and feeble. It is often the 
first stage in the development of phthisis. 

SYMPTOMS. 
Rational. 

Pain— is rare (but there is, often, a sense of uneasiness after exer- 
cise). 
Emaciation. 
Dyspnoea — on exertion. 
Cough. 

Expectoration— muco-purulent, or mucus. 
Pulse— smaU and feeble (110 to 120). 
Dryness of the skin — (especially at night). 
Temperature — about 101°. 
Countenance — pale and anxious. 

Breathing — short and catching (patient can only lie on the affected 
side). 

In the active form. 

The symptoms are active. They xvill increase for a time; then 
cease; and subsequently return with greater severity. There 
is a rapid increase of fluid, causing intense dyspnoea and 
cyanosis, and oedema of the other side (from the pressure 
created). Patient is frequently unable to lie down. 
Physical. 

If the cavity be partly or completely filled. 

Inspection — the afi:ected side is enlarged in all directions. Bulg- 
ing of the intercostal spaces may be detected. Respiratory 
movements on the affected side are upward and downward, 
and are increased laterally on the other side. There may be 
entire g-bsence of respiratory movements on the affected side. 
The heart is displaced; a fullness, below the ribs, in the abdo- 
men may exist (from the liver being pushed down below the 
free border of the ribs). 

Mensuration — the affected side is larger than normal after expi- 
ration, (one or two inches). 

Palpation — complete absence of vocal fremitus. 



88 



DISEASES OF THE RESPIRATORY ORGANS. 



Percussion— flatness of the affected side (below the level of the 
fluid). 

Auscultation — entire absence of the respiratory and vocal sounds 
(below the level of the fluid). Bronchial respiration and 
bronchophony above the fluid (if the lung be sufficiently com- 
pressed). 

As absorption takes place, the vocal sounds return to normal, and 
a creaking, mbbing, friction sound is produced as the two 
surfaces play on each other. The surfaces of the pleura are 
thickened (due to new connective-tissue formations). The 
vocal fremitus is diminished; the respiration is feeble; and 
there is dullness on percussion, with a tendency to return to a 
vesicular quality, as the lung expands. 

DIFFEEENTIAL DIAGNOSIS. 
From pneumonia; consolidation of the lung; enlarged spleen 
and liver; cancer of the lung and pleura; and aneurism. 
From pneumonic and phthisical consolidation of the lung. 
There is the history to aid in the discrimination. 
The expectoration of pneumonia is pink, brick- dust, or 

" prune-juice." 
The expectoration of phthisis is streaked with blood. 
Percussion— tlnevQ is dullness, but not a flatness which changes 

with the position of the patient (as in pleurisy). 
Auscultation — vocal fremitus is intensified and increased; the 

respiration is feeble; bronchial and moist rales exist. 
The symptoms of pulmonary consolidation begin from above; 
extend downward; and are often bilateral. 
From the spleen (vNdien enlarged). 

The enlargetjnent extends upward and downward: is confined 
to the abdominal cavity ; and there is continuous dullness. 
From cancer of the lung. 

Aspiration with the hypodermic needle, and the microscope 
will settle the question; and the physical signs may assist 
in the diagnosis. 

PROGNOSIS. 

Is good, if there is no complication; but if there is over-disten- 
tion from fluid and marketl dyspnoea, the prognosis is bad. 



CHRONIC PLEURISY. 



89 



TREATMENT. 

Syrup of the iodide of iron {li.), three or four times daily 
should be given; also a large amount of good nutritious food. 
The patient may be given a bottle of wine daily, and the nutritive 
process should be raised to the highest possible degree; as, by keep- 
ing up the vital powers to their utmost, you thus aid Nature to 
get rid of the fluid in any serous cavity. Cathartics, diuretics, 
diaphoretics, or blood-letting should never be resorted to, as there 
is too great an increase of fibrin, and they have no power to re- 
move it. 

Aspiration (see hydro-pneumo-thorax) should be resorted to 
early if the effusion is very great, until all the fluid, necessary to 
relieve extreme pressure, is removed; but great care should be 
used, as pulmonary emphysema or phthisis may ensue if carried 
too far. In the young, a systematic course of gymnastics may be 
resorted to in order to overcome the adhesions (should they 
occur). 

CHEONIO PLEUEISY. 
SYNONYM. 

Empyema. 

DEFINITION. 

There is pus, or a purulent exudation, in the cavity of the 
pleura ; due to an inflammation, which may be primary or 
secondary, and which comes on gradually (in the majority of 
cases). 

MORBID ANATOMY. 

A pouring out of plastic material, which undergoes trans- 
formation into pus, occurs (especially in pysemia and septiceemia); 
and a migration of white blood-corpuscles through the w^alls of 
the blood-vessels into the connective-tissue of the pleura, from 
wiiich they are washed by the serous effusion, and held in suspen- 
sion, may also take place in other conditions. The exudation is at 
first clear; but, later on, consists of yellow, greenish-yellow pus 
(primary empyema); this exudation goes on increasing, causing the 



90 



DISEASES OF THE RESPIRATORY ORGANS. 



pleura to become a "pyogenic membrane " (produced by excessive 
irritation). If the irritation is mild, the cell-production may be 
circumscribed and not general. The accumulations may escape 
by spontaneous openings, such as perforation of the chest-walls by 
ulceration; perforation of the lung, and its escape by the bronchi; 
perforation through the diaphragm, entering the abdominal 
cavity, producing fatal peritonitis and death ; or into the intesti- 
nal canal, through adhesions between the intestines and the 
diaphragm, when pus will appear in the discharges from the 
bowels. If recovery takes place, there is a general contraction, 
by cicatrization, of all the viscera, to fill up the gap and stop the 
purulent discharge. 

ETIOLOGY. 
Exciting Causes. 
Traumatism ; broken down subjects ; phthisis; protracted ex- 
haustive diseases (as advanced phthisis, suppuration of bones, 
chronic syphihs, chronic alcoholismus, cancer, or special vice). 

SYMPTOMS. 
Rational. 

Pain — is rare. 

Uneasiness and weight on the affected side. 

Countenance — pale and anxious. 

Hectic chill, fever and sweating (at intervals). 

Cough. 

Expectoration — muco-purulent, and not abundant. 
Dyspnoea. 

Development of a condition similar to that of phthisis. 

Semi-comatose state — if pyaemia or septicaemia occur. 

Protrusion of a tumor — between the ribs (which fluctuates and is 
red, if about to discharge externallyj. 

Pneumonic signs — (if the discharge take place through the lungs) 
such as chill, cough, fever, profuse muco-purulent expectora- 
tion with blood, retraction of the chest- walls, etc. 
Physical. 

Same as those of the subacute form, excepting that the level of 
the fluid does not change so readily. 



HYDRO-PNEUMO-THORAX. 



91 



DIFFERENTIAL DIAGNOSIS. 
Is impossible, except by aspiration. Is chiefly mistaken for 
pleurisy. 

PROGNOSIS. 

Is bad. It is stated, that one in every five recover from sponta- 
neous openings ; and. one-eighth, where aspiration is resorted to. 
Death occurs -from exhaustion. 

TREATMENT. 

Early aspiration. The patient should be placed upon the most 
nutritious diet, and only a small amount of stimulants given. 
Iron, quinine, and cod-liver oil are the best medicinal agents to 
rely upon. Let the patient be in the open air as much as is possi- 
ble, or order a change of climate. 

HYDRO-PNEUMO-THORAX. 
DEFINITION. 

Is a condition, characterized by the presence of fluid and air 
within the pleural cavity. 

MORBID ANATOMY. 
The changes are the same as in empyema. There may be a 
great quantity of air and small amount of fluid in the pleural 
cavity, or the reverse. 

ETIOLOGY. 

Traumatic perforation of the chest-wall ; perforation of the 
lung by tubercle, cancer, etc. ; traumatic rupture of an emphyse- 
matous lung; fracture of the ribs; or gangrene of the lungs. 

SYMPTOMS. 
Rational. 

Dyspnoea — extreme (when the air first enters). 
Pain— (intense and thoracic) of the affected side. 
Cyanosis— very marked at onset. 

Collapse and death — may occur from shock, but continued dys- 



92 



DISEASES OF THE RESPIRATORY ORGANS. 



pnoea ; filling up of the chest with fluid (usually pus) ; general 
dropsy ; or hectic fever most often follow^ 
Symptoms of exhaustion or cyanosis (from pulmonary oedema). 
Physical. 

Inspection — bulging of the affected side ; diminished movement 
of the chest. 

Palpation — absence of vocal fremitus on the affected side. 
Percussion — tympanitic, above the fluid ; flatness, below the fluid. 
Suceussion — (a splashing sound heard on shaking the patient). 
Auscultation — "metallic tinkle " (due to the dropping of fluid 
from the lung into the fluid below). — Amphoric respiration. 
The pathognomonic sign of fluid in the cavity is dullness on per- 
cussion, and alteration of the dullness, due to the change in posi- 
tion of the patient. This fluid may, however, be held down by 
adhesions (or encapsulated), so that its position is not altered, in 
which case this sign will be absent. 

DIFFERENTIAL DIAGNOSIS. 
From pneumo-thorax; obstruction to a bronchus; emphysema 
(if extensive); or a large cavity in the lung. 

PROGNOSIS. 

Is unfavorable' in every case; and rapidly fatal, if due to pul- 
monary gangrene or phthisis. 

TREATMENT. 

Is palliative. Inject morphine hypodermically. If the patient 
survive the first few days, give stimulants and good nutritious 
diet. Paracentesis should only be resorted to in extreme cases. 
In performing aspiration, place the arm of the affected side at 
right angles across the chest, and insert the canula (for a distance 
of two inches) at a point situated about the line of the sixth rib 
and at the junction of the infra-scapular and axillary regions; so 
soon as the patient complains of restriction, stop the operation; 
then wait for a day or two before performing it again. This oper- 
ation should be persevered in until the fluid gets below the line of 
the scapula. 



HYDRO-THORAX. 



93 



HYDRO-THORAX. 
DEFINITION. 

Is a non-inflammatory accumulation of fluid within the pleural 
cavity. 

ETIOLOGY. 

It occurs in general dropsy of Bright's disease ; in the course of 
general hydraemia; or chronic exhaustive diseases; in valvular 
heart-lesions; or it may be due to mediastinal tumors. 

SYMPTOMS. 

Rational. 
Dyspnoea— steady and progressive. 
Cyanosis — increasing steadily. 
Respiration— gasping (when the fluid is excessive). 
Inability to lie down. 
Pulse — feeble and small. 
Temperature — not increased. 
Articulation — monosyllabic (in advanced stages). 

Physical. 

Inspection — gradual impairment of motion of the chest, and bulg- 
ing of the two sides. 

Percussion — flatness, below the level of the fluid, which changes 
with the attitude of the patient. 

Auscultation — absence of the vocal sounds, below the level of the 
fluid. 

DIFFERENTIAL DIAGNOSIS. 
From subacute pleurisy; and pulmonary oedema. 

PROGNOSIS. 

Is modified by the cause, and condition of the patient. It may 
prove a direct cause of death in Bright's disease, or when a chronic 
heart-affection exists. 



94 



DISEASES OF THE RESPIRATORY ORGANS. 



TREATMENT, 

The use of hydragogue cathartics and diuretics, and those agents 
which are employed to remove fluid from the areolar tissue, has 
been long in vogue; but thehestmodeof treatment is the aspirator. 

PHTHISIS. 
DEFINITION. 

Is a ''wasting away" or molecular death of the lung-substance. 

VARIETIES AND SYNONYMS. 
" Catarrhal " or " chronic catarrhal pneumonia " — where the 
disease is a continuation of a pneumonia (catarrhal type). 
Fibrous" or "cirrhosis" or " induration "—where the con- 
nective-tissue groivth is prominently developed. 
^'Tubercular" or "acute miliary tuberculosis" — where 
miliary tubercle is deposited within the lung in the lymphatic 
structure. 

MORBID ANATOMY. 
Catarrhal form. — There has been a previous catarrhal or 
lobular pneumonia, which has not been followed by resolution dur- 
ing the third stage; but ^Yho^Q products have become caseous. This 
caseous matter creates ulceration of the lung by acting as a foreign 
body, and, possibly induces miliary tuberculosis by absorption. 
In rare cases, this caseous matter may become encapsulated and 
innoxious. 

Fibrous form. — There ^ (1) proliferation of new connective-tis- 
sue cells in the lung; (2) organization of these cells and formation 
of new connective-tissue; (3) contraction of this new connective- 
tissue, creating pressure on the vesicular structure. 

Tubercular form. — There is absorption of caseous matter from 
some other part of the body resulting in lymphatic formation 
in the peri-vascular spaces of organs (especially of the lungs), 
which under the microscope shows giant cells. The tubercles 
subsequently undergo ulceration and excavnlio;! (probably by ths 



PHTHISIS. 



95 



pressure exerted on the blood-vessels, causing impairment of 
nutrition). 

ETIOLOGY. 
Predisposing Causes. 
Hereditary or acquired constitutional debility. — Bad hygiene. — 
Damp, cold climate. — Badly drained, or miasmatic soil. 
Exciting Causes. 
Extension of a bronchial catarrah. — Pneumonia. — Subacute pleu- 
risy. — Inhalation of irritating particles or gases. ^ — Exposure to 
cold, or sudden changes in temperature. 

SYMPTOMS. 
Rational. 
Constant elevation of temperature. 
Cough — dry, hacking or paroxysmal in early stages. 
Expectoration — streaked with blood, often slight in amount (indi- 
cating lobular consolidation). 
Haemoptysis. 

Emaciation — steady and gradual. 

Night-sweats— commence early in the disease. 

Dyspnoea — at first, only after exertion; but, later on, a constant 

symptom. 
Pain in chest— due to local pleurisies. 
Hectic fever — when cavities are formed. 
Pulse — accelerated (100 to 140), corresponds to temperature. 
Disturbance of digestive function. 
Vomiting — usually due to reflex causes. 

Diarrhoea (bad symptom)— due (1) to indigested food ; (2) follicular 
ulceration of the small intestines ; (3) ulceration of the large 
intestines (occurring usually in later stages) 

Arrest of menstmation — (is often an early symptom). 

Aphonia — partial (from ulceration of the larynx). 

(Edema of legs and feet — (due to thrombosis in lower extremi- 
ties). 

Clubbing of the finger nails. 

Fatty liver — (is possible), consists of simple deposit of fatty matter. 
Pac'j — peculiar clearness of the sclerotic. 



96 



DISEASES OP THE RESPIRATORY ORGANS. 



Increased sexual desire. 

Cyanosis (when the disease is extensive). 

Physical. 

Stage of Consolidation. 

Inspection — sHghtly diminished expansion of the chest. De- 
pression in the infra-clavicular spaces. 
Palpation — vocal fremitus increased. 

Percussion — Slight dullness (as compared with the other side). 
Auscultation — Respiration, rude or bronchial. Prolonged and 
high-pitched expiration. Rales — suhcrepitant. mucous, 
crepitant, or metallic. Vocal resonance intensified. 
All of these symptoms of the first stage are important, as they 
often enable the practitioner to offer a favorable prognosis. They 
should be always determined by a comparison hetiveen the two 
lungs. 

Stage of Softening. 

Inspection — diminished expansion of the chest. Respiration 
more frequent. Marked depression above and below the 
clavicle. 

Palpation — increased vocal fremitus. 
Percussion— diuWne^s increased (wooden). 

Auscultation — bronchial breathing. Abundant rales, circum- 
scribed and bubbling. Crackling sounds, at certain spots. 
Stage of Excavation. 

Inspection — retraction of chest-walls. 
Percussion - Dull, amphoric, or cracked-pot. 
Auscultation — Respiration, cavernous or bronchial, and 
gurgles. Cavernous whisper." 

DIFFERENTIAL DIAGNOSIS. 
From bronchitis (all forms) ; croupous pneumonia, especially if 
at apex or accompanied by typhoid fever; pleurisy; pulmonary 
infarction and haemoptysis. 

PROGNOSIS. 

In the catarrhal form, the disease may often be arrested, in its. 
first stage, by change of climate. 



PHTHISIS. 



97 



If the tubercular variety exist, the prognosis is unfavorable. 

If the fibrous form be developed, the prognosis is good as regards 
duration of life. If complications arise, as laryngitis, pulmonary 
oedema, capillary bronchitis, pulmonary congestion, or profuse 
hemorrhage, the prognosis is bad. 

TREATMENT. 

Is usually considered under three heads: 

First. — The prophylactic treatment. 

Second. — Hie medicinal treatment. 

Third. — Ttie hygienic treatment. 

The most satisfactory results are usually obtained where the 
prophylactic treatment can be resorted to early; for, if the patient 
live in a district which subjects him to any form of depression, a 
change of residence should be insisted upon. A phthisical, or deli- 
cate mother should never be allowed to nurse her infant, but a 
wet-nurse should be procured. During childhood, the offspring 
should be fed on cow's milk and removed to the country, where 
it can have plenty of good fresh air, and physical training. Those 
who are predisposed to phthisis should never be allowed to breathe 
an atmosphere laden with dust or charged with poisonous vapors; 
neither should they be exposed to sudden changes in temperature. 
This class of patients should always sleep in large and well- venti- 
lated rooms, and free from overcrowding. Physical exertion, 
such as violent running, jumping, etc. , should be avoided.. The 
surface of the body should be always covered with flannel. The 
diet should be simple, and taken at regular intervals, and consist 
of such articles as the stomach is able to digest without any sen- 
sation of weight or pain. Stimidants should only be resorted to 
in case of extreme fatigue or severe exposure to cold, as the con- 
stant use of them is injurious. This class of patients is very 
susceptible to catarrh on the slightest exposure, and these attacks 
should be treated with the greatest care; but, if it shall have 
reached the smaller bronchi, there is nothing so certain to remove 
the catarrh as a change in climate. In order to carry out this 
form of treatment most effectively, the vital powers of the patient 
should be sustained, so that he should not become susceptible to 
the local causes of phthisis. 



98 



DISEASES OF THE RESPIRATORY ORGANS. 



Tlie Medicinal Treatment. — The worst symptom to be encoun- 
tered in this disease is fever. By the rise in temperature, it is 
evident that a bronchitis has resolved itself into a broncho-pneu- 
monia; by a still greater rise, the products are becoming cheesy; 
and by the hectic fever and night-sweats, softening is commenc- 
ing. It is therefore essential that the temperature should be at 
once reduced, and the only drug which can be relied upon is sul- 
phate of quinine. This drug has also been regarded as a power- 
ful agent in the relief of night-sweats; there is no djubt that it 
has this power, but it must be borne in mind that night-sweats 
are onl}^ a part of the fever, and that in controlling the one you 
control the other. When the first elevation of temperature 
occurs, quinine (gr. xx. per diem, given in one or two doses), 
rarely fails to control the temperature, diminish the frequency of 
the pulse, and arrest symptoms which are liable to result from 
the fever. It will be well to determine the time at which the 
highest temperature occurs and admmister a large dose one or two 
hours preceding the attack, and continue it for as long a period as 
possible without producing cinchonism or until the temperature 
falls. Cod-liver oil is another medicinal agent. If possible, it 
should be given with an alkali in smaU doses, and not often re- 
peated. A teaspoonful once or twice a day is sufficient to com- 
mence with. It may be gradually increased to a tabk spoonful 
three times a day. Avoid administering it m connection with 
stimulants, unless the patient cannot take it m any other way. 
There are three forms which afford some clue to the mode of its 
action. First, unless the patient gains weight while using it, it 
seldom if ever proves remedial; secondly, flesh and weight maybe 
gained during its administration and still the phthisical processes 
steadily progress; thirdly, when it does act remedially, the weight 
gained is far greater than would result from the oil as a mere 
element of nutrition. The lujpopliospliates of lime are only ser- 
viceable when intestinal digestion is imperfect. Iron is only of 
service when there is no marked fever: since if administered when 
there is fever the digestion will be distm*bed and diarrhoea prob- 
al)ly ensue. Stimulants maybe given when they increase the 
desire for food and assist digestion, or when their use is followed 



PHTHISIS. 



99 



by a feeling of increased strength and a disposition to take exer- 
cise; but if they produce symptoms of fever and depression they 
will do harm. Opium should never be given in any stage of 
phthisis unless the cough is distressing and the patient is unable 
to obtain the requisite amount of sleep; under such circumstances 
the inhalation of a few drops of chloroform is preferable to opium. 
Vomiting after meals is often a troublesome attendant of this dis- 
ease. The best means to be adopted in this case is to compel the 
patient to take, every half -hour for forty-eight hours, about a tea- 
spoonful of raw scraped beef made into a sandwich, at the same 
time keeping absolutely quiet in a recumbent position. 

The Hygienic Treatment. — This mode of treatment is by far the 
most important to phthisical subjects. It will be well to bear in 
mind the following rules, which will greatly assist in alleviating 
the sufferings of the patient: 

1. It is absolutely necessary that there should be a good supply 
of pure and fresh air. 

2. Exercise in the open air should be resorted to daily, when 
practicable. 

3. The climate in which such patients should live, must be uni- 
form, sheltered, temperate, and mild (about 60°), with a range of 
not more than 10° to 15° during the year. A cold, dry climate 
often agrees with some patients of this class; its beneficial effect 
can be estimated by the relief afforded to the cough and a ten- 
dency to produce healthy sleep. The soil should be dry, and the 
drinking water pure and not hard. 

4. The dress should be of such a character as to equalize and 
retain the temperature of the body. 

5. Late hours should be particularly avoided, as also indoor and 
sedentary occupation. 

6. Cleanliness, which is reputed to be next to godliness, should 
be scrupulously attended to. 

7. The diet should be most nutritious, easy of digestion, and 
more or less varied; and the number of meals should not be re- 
stricted. Milk, eggs combined with milk, beef tea (as a concen- 
trated nutrient), and koumiss (made from asses' milk), are highly 
recommended for this class of patients. 



DISEASES OF THE CIEOULATOEY 
SYSTEM. 



DISEASES OF THE PEEICAEDIUM. 



The pericardium is composed of two layers (a fibrous and serous). 
The fibrous layer is closely attached to the diaphragm: the serous 
closely adheres to the internal surface of the fibrous layer, is re- 
flected from the large vessels, and completely invests the heart. 

ACUTE PERICARDITIS. 
DEFINITION. 

Is an inflammation of the covering membrane of the heart 

MORBID ANATOMY. 

The serous surface is more or less reddened with ecchymotic 
spots; the reddening may be circumscribed or diffused; and the 
discoloration is due to hypersemia of the sub-serous capillary 
vessels. There is also swelling and infiltration of the sub-serous 
tissue ; while the epithelial covering is separated and thrown off, 
thus losing its natural, brilliant appearance. If the inflammation 
ia continued, an exudation is poured out on to the free pericardial 
surface. 

The plastic exudations vary in thickness, accumulating on the 
cardiac and parietal surfaces, or the cardiac surface alone. As 
soon as the plastic material is poured out, it causes roughening of 
the pericardium (commonly called "hairy heart"). The fluid 
may be sero albuminous, sero-fibrinous, hemorrhagic, or puru- 
lent. There may often be from three to twelve fiuid ounces in 
the sac (which is usuaUy sero-fibrinous in character); sero-albumin 
ous fluid is very rare. If the pericardium is fllled with fluid, the 
lung becomes compressed. The effusions may undergo absorption, 
or remain as cheesy masses. Bands, or adhesions may form, or 
there may be agglutination of the surfaces and obliteration of the 



104 



DISEASES OF THE CIRCULATORY SYSTEM. 



pericardial cavity. Myocarditis may be produced by extensive 
and long-continued pericarditis, producing weakness of the walls 
of the heart. Dilatation of the cavities may also take place through 
the weakened condition of the heart-walls, and hypertrophy may 
be developed as a result of this weakening, or as a secondary 
result of dilatation. 

Post-mortem shows, white spots on the external surface of the 
heart, caused by a growth of connective-tissue beneath the cardiac 
pericardium ; this is really a localized pericardial inflammation 
without adhesions. The two surfaces of the pericardium may 
also be found to be agglutinated, causing obliteration of the peri- 
cardial cavity. 

ETIOLOGY. 

It is always a secondary disease, and occm's chiefly in young 
people. It may arise from inflammation of the neighboring 
organs, as in pneumonia ; pleurisy; neurosis of the sternum and 
the ribs ; and from certain blood-diseases, as acute rheumatism, 
Bright's disease, scarlatina, small-pox, typhus, tuberculosis, 
syphilis, alcoholism, scurvy, purpura, etc. 

SYMPTOMS. 
Rational. 

It comes on insidiously, as a rule, on account of its frequent com- 
plication with other diseases. 

Pain in the precordial space— slight or lancinating, involving the 
brachial plexus, extending down the arm, and increased by 
pressing up the diaphragm. 

Cough— dry, irritating, and a sense of constriction over the chest. 

Dyspnoea— depends upon the amount of fluid effusion present. 

Countenance— anxious. 

Restlessness— if the effusion be considerable in amount. 

Posture — half sitting, and leaning towards the affected side ; or 

on the back with the head elevated. 
Pulse— (before fluid effusion) full and strong (90 to 120); (after fluid 

effusion) feeble, suppressed, delayed, or intermittent. 
Temperature — usually, about 100°; sometimes below normal, 

which is a serious symptom. 



ACUTE PERICARDITIS. 



105 



Headache — frequent dizziness. 
Delirium — active (occasionally). 

Syncope— on moving, if the fluid be extensive. This is probably a 

symptom of myocarditis. 
Heart's action -forcible and irritable. There is an increased area 

of apex-beat. 
Palpitation — (due to compression of the heart). 

Physical. 

Inspection — diminished respiratory movements, over the pericar- 
dial space.— If the pericardial sac be distended, there is arch- 
ing of the precordial region froni the second to the sixth 
intercostal spaces. 
Palpation— the apex-beat is raised and carried to the left.— if ef- 
fusion exist — cardiac excitement and friction fremitus dis- 
appear ; the apex-beat is feeble, or imperceptible ; and an 
undulating impulse is felt. 
Percussion — If effusion exist — dullness is increased laterally and 
vertically. — Laterally — from one nipple to the other (in 
marked cases). — Upward— as high as the second or first rib. 
Downward — more than normal (displacing the diaphragm). 
During stage of Plastic Effusion. 

Auscultation. — Pericardial friction sounds, may be single or 
double, and independent of the heart-sounds; are super- 
ficial, and may, or may not accompany the heart- sound ; 
the maximum of intensity is at the junction of the fourth 
rib and the sternum on the left side. — The intensity of the 
friction sounds increases by change in position, and also 
by a full inspiration (due to pressing of the two pericardial 
surfaces together by the distended lung). 
During Stage of Fluid Effusion. 

An absence of respiratory murmur may exist (from the lung 
being pushed to the right and left, by the distended peri- 
cardial sac), and the heart's sound may be rendered feeble 
or be entirely lost. 
Stage of Absorption. 

On recovery taking place, the bulging subsides ; the dullness 
decreases ; the sufaces come together and often adhere 



106 



DISEASES OF THE CIRCULATORY SYSTEM. 



(due to the inflammatory process) ; the friction sounds 
reappear; the heart sounds are more distinct; the^ apex- 
beat becomes normal ; the cardiac impulse returns ; and 
the respiratory and vocal sounds are again detected. 

DIFFERENTIAL DIAGNOSIS. 
Between pericardial friction sounds, and endocardial murmurs. 
Betweea pericardial friction sounds, and pleuritic friction sounds. 
Between pericardial effusion, and hypertrophy and dilatation of 
the right ventricle. 

PROGNOSIS. 

There is generally complete recovery, except when it occurs in 
connection with Bright's disease, and septicaemic and pya?mic 
conditions. If pyeemia exist, you have a purulent exudation 
which is rarely absorbed. The nature of the exudations deter- 
mine the prognosis. Acute pericarditis may become chronic, or 
be accompanied by large serous effusions which disappear slowly 
and may be accompanied by relapses. It may create extreme 
dyspnoea and, in rare cases, fatal syncope. If there is a long con- 
tinuance of the fluid, the heart softens, and there is degeneration 
of its muscular tissue; this organ then becomes enfeebled, its 
force diminishes, and death ensues from oedema of the lungs, 
possibly associated with blood-changes, from loss of red blood- 
globules and fibrin. If it occur from acute rheumatism, it is 
rarely fatal ; but you have as sequelae, adhesions of the two sur- 
faces, cardiac dilatation, and hypertrophy. This dilatation is due 
to a weakness of the walls of the heart from the inflammatory 
process; and the hypertrophy which follows the dilatation is com- 
pensatory. There are also further sequelae, such as abundant 
exudations, and extensive adhesions at the base of the heart, 
causing contraction, pressure, and possible obstruction through 
the coronary arteries, producing fatty degeneration of that organ. 

TREATMENT. 

You must support your patient. First seek the cause arid re- 
move it. If it be due to fevers and tlie resulting depression, or to 
pyaemia, or septicaemia, give stimulants in moderation. In the 



CHRONIC PERICARDITIS. 



107 



early stages of the disease, hot anodyne poultices (opium, bella- 
donna, etc.) should be employed. Give opium internally in small 
doses; the largest doses may be given at night in order to produce 
a quiet sleep, but it should never be carried to narcotism. If there 
be effusion, it should be removed by medical measures, if possible. 
If you are able to sustain your patient, and there are no evidences 
of pulmonary congestion and oedema, immediate interference may 
be delayed. Do not employ hydragogue cathartics, blisters, etc., 
as the disease, in all cases, is due to some previous weakening dis- 
ease, and consequently these remedies make it worse. Iron and 
stimulants should be used in moderation; also concentrated nutri- 
tion. The patient should be placed in bed and kept perfectly 
quiet. The chest must be protected from cold, and anything that 
accelerates the heart's action be avoided. In convalescence, the 
patient must be watched on account of the weakness of the heart's 
walls, and dilatation and hypertrophy that are present. If there 
be pus in the pericardium, then aspirate, and only for that condi- 
tion. 

CHRONIC PERICARDITIS. 
MORBID ANATOMY. 
In some cases, the pericardial sac contains fluid, adhesions^ 
chalky debris, and calcareous plates. 

ETIOLOGY. 

If the acute form does not terminate in three or four weeks, it 
may be considered as of the chronic type. 

SYMPTOMS. 
Rational. 

Obstructed circulation. 

Enlarged heart (as shown by percussion and position of apex-beat). 
Dyspnoea (from pressure on the lung and weak heart's action). 
Sense of weight in the precordial region. 
Angina pectoris — (in some instances). 
Palpitation— on slight mental or physical exertion. 



108 



DISEASES OF THE CIRCULATORY SYSTEM. 



Physical. 

Inspection, — Depression of the precordial region may occur (from 
firm adhesions taking place between the pericardium and the 
chest-walls). 

Palpation. — Apex-beat is indistinct, and often two inches higher 
than normal. Displaced cardiac impulse, unattended by 
change of position of the organ. Irregular movement of 
heart, in systole and diastole. 

Percussion, — Increased dullness, in the pericardial region. 

PROGNOSIS. 

Is doubtful; especially when degeneration of the cardiac walls 
and valvxdar insufi&ciency exist. 

TREATMENT. 

Limit the physical exercise so as not to overtax the heart. The 
diet must be most nutritious, but not stimulating ; administer 
iron. 

HYDKO-PERICARDIUM. 
DEFINITION. 

Is a non-inflammatory sero-albuminous exudation into the 
pericardial cavity, rarely causing death. 

• ETIOLOGY. 

It occurs most often in renal diseases, which are liable to com- 
plicate scarlatina; also in chronic Bright's disease; general dropsy; 
and chronic cardiac disease, (result of venous congestion), 

SYMPTOMS. 

The same as those which occur in the stage of fluid effusion of 
pericarditis, except that there is no febrile disturbance, neither 
are there any friction sounds present at any time during the pro- 
gress of the effusion. 

PROGNOSIS. 

Is a precursor of death in chronic Bright's, and advanced car- 
diac diseases. 



TUBERCULOSIS OF PERICARDIUM. 



109 



TREATMENT. 

The same as in hydro-thorax. Treat the disease that caused it. 

PNEUMO-PEEICAEDIUM. 
DEFINITION. 

Air in the pericardium, due to compound fracture of the ribs, 
or external wounds, or, to the ulcerative process of phthisis. 

DIAGNOSIS. 

This rests almost exclusively upon the tympanitic percussion 
over the precordial space, and, the tinkling and splashing sound 
which is heard over the heart. 

PROGNOSIS. 
Is always fatal — except when due to traumatism. 



H^MO-PERIOAEDIUM. 
ETIOLOGY. 

Blood in the pericardial sac may be due to traumatism; rupture 
of the cardiac walls; or distention of the pericardium with blood 
from rupture of an aneurism, septicaemia, pyaemia, scurvy, pur- 
pura, etc. 

PROGNOSIS 
Unless traumatic, is rapidly fatal. 



TUBERCULOSIS OF PERICARDIUM. 
ETIOLOGY. 



Is only met with in acute general tuberculosis, producing 'peri- 
carditis. It may be suspected, if general tuberculosis be present. 



110 



DISEASES OF THE CIKCULATORY SYSTEM. 



CANCER OF THE PERICARDIUM. 
ETIOLOGY. 

This disease is always secondary to cancerous developments in 
other parts of the body. 

ACUTE ENDOCARDITIS. 
DEFINITION. 

Is an inflammation of the (serous) lining membrane of the heart, 
from blood-changes, causing alterations especially in the neighbor- 
hood of the valves, and, i^ossibly, involving the whole endocardial 
surface of a ventricle or auricle. Is most common in left heart. 

VARIETIES. 

Acute, which gradually runs into chronic, with no defined line 
of separation; except, that the acute symptoms last three or four 
weeks, and then the disease becomes chronic in character. 

MORBID ANATOMY. 
Ist.^^There is hyperasmia of the endocardium, most marked 
about the edges of the valves. 

• 2d. A plastic exudation on the free surface (which is washed off 
by blood), occurs at the same time; also a growth of new cells 
underneath the inflamed portion of the endocardium, which by 
their presence produce irregularities upon the free surface of the 
valves. The valves are also somewhat tumefied by inflammatory 
oedema. 

3d. The elevations, on the free surfaces of the valves, produced 
by the new cell-growth underneath the endocardium, create a- 
deposit upon them of the fibrin of the blood, resulting in the so- 
called "vegetations." 

4th. The new cell-growth under the endocardium organizes into 
new connective-tissue; and this subsequentlj'- contracts, causing 
an imperfect performance of the function of tlie valves. 



ACUTE ENDOCARDITIS. 



Ill 



5th. The free edges of the valves sometimes become adherent 
to each other, producing stenosis or the so-called ' button-hole 
slit." . 

ETIOLOGY. 

All morbid changes in the blood, causing irritation to the free 
surface of the endocardium over which it passes; Bright's disease 
— from irritation produced by the urea in the circulation; and 
acute articular rheumatism (sometimes). Whenever it occurs, it 
is due to some changes in the salts of the blood, or to a distinct 
poison, acting as an irritant to the valvular surface of the endo- 
cardium. The primary seat of the inflammation is in the serous 
structure, and the changes in the fibrous framework are second- 
ary. It may occur in diphtheria, septicaemia, pyaemia, and fevers 
of all kinds. Secondary syphilis, which causes catarrh of the 
urinif erous tubules and amyloid kidney, may thus tend to create it. 

SYMPTOMS. 
Rational. 

Pain — in the joints (if rheumatism be present). 

Palpitation — over the precordial space (if the muscular tissue of 

the heart is involved). 
Pulse— is sharp, quick, and irregular; but feeble and compressible 

when myocarditis occurs. 
Temperature— rarely over 103°. 

Dyspnoea — slight; the respiration is usually somewhat accelerated. 
Physical. 

Inspection — Increased area of heart's mpulse. Irregular heart's 

action — indistinct later on in the disease. 
Palpation — Cardiac impulse is increased at first, and afterward 

decreased. 

Percussion. — The precordial dullness is normal (until the cavities 
are distended with blood from feebleness of the heart); then 
the dullness is increased. 

Auscultation.— ^Y^ioliG, ventricular valvular murmurs are heai- i 
If it is produced at the mitral or tricuspid orifice, it is duo 
to the tumefied condition of their edges and shortening of 



112 



DISEASES OF THE CIRCULATORY SYSTEM. 



the chordae tendinese, or to adhesions. If it occur at the 
aortic orifice, it is due to a simple roughening of the endocar- 
dium covering the aortic valves, and a soft, blowing, systolic 
murmur is thus produced. 

DIFFERENTIAL DIAGNOSIS. 
First, determine if it is an old or recent murmur. If it should 
happen to be an old murmur, there will be compensatory hyper- 
trophy of the heart. If it be due to acute i;lieumatism, there will 
be an endocardial murmur, which will come on while the case is 
under your care. Should there be a murmur at your first visit, 
which is systolic, soft, and blowing in character, and no hyper- 
trophy, it is produced probably by an acute endocardial inflam- 
mation: but if the murmur is rough in character, diastolic, and 
associated with cardiac hypertrophy, there is no evidence of acute 
endocarditis. 

For the differential diagnosis from pericarditis (see acute peri- 
carditis). 

PROGNOSIS. 

Is good, so far as imminent danger to life is concerned, but bad 
as regards complete recovery. Is rarely fatal, if occurring in 
Bright's disease, or rheumatism (still there will always be per- 
manent valvular lesions). Is fatal, if it occur in pygemia, septi- 
caemia, and diphtheria (the danger being perforation of the valves 
or embolism). The organs which are most likely to be affected 
from an embolus, during this disease, are the spleen, kidneys, and 
the brain. Embolism of the spleen is characterized by pain or 
swelling over the spleen; pain in the loins and albuminuria mark a 
similar condition of the kidney; sudden hemiplegia occurs from a 
similar brain complication. If ulcerations occur at the free border 
or base of the valves, they may cause a rupture or tearing of the 
valves; following this there is a tendency to weakness and typhoid 
symptoms, extreme dyspnoea, cyanosis, and a sudden harsh regur- 
gitant murmur, with the first or second sound of the heart. The 
disease may prove fatal in a few hours, or at most from three 
to four days, if such a condition be developed; the duration of life 
depending upon the size of the abnormal opening. 



ULCERATIVE ENDOCARDITIS. 



113 



TREATMENT. 

If it be due to rheumatism, rheumatic treatment must be resorted 
to. If from pyaemia, septicaemia, or diphtheria, quinine and iron 
must be freely administered. If from fevers, the temperature 
must be held in check. If from Bright's disease, the urea 
must be ehminated. Opiuyn should be given moderately in order 
to secure rest. The patient must alivays he kept perfectly quiet ; 
the temperature of the room should never be below 70°; the chest 
should be covered with flannel, especially while examination of 
the heart is being made. The patient must be fed with the most 
concentrated nutrition. Digitalis should be administered if the 
heart become feeble. Iodide of potassium has been recommended 
to absorb the fibrinous exudation. 

The most efficacious agents in the treatment of this disease will 
be found in rest, opium, iron, the most nutritious diet, and the 
occasional use of stimulants. 

ULCERATIVE ENDOCARDITIS. 

MORBID ANATOMY. 
In this form of endocarditis the new cell-growth is so rapid that 
the connective-tissue is not formed and pus results; under these 
circumstances the endocardium either ulcerates, or the entire 
^ valve may be perforated. 

ETIOLOGY. 

It occurs in pyaemia, septicaemia, puerperal fever, and in dis- 
eases characterized by great vital depression. 

SYMPTOMS. 
Rational. 
Chills — previous to the attack. 
Pulse— 90 to 150 (at tlie time of the attack). 
Temperature- 105° to 107°. 

Dyspnoea — extreme and sudden, when perforation takes place. 
Posture— sitting. 



114 



DISEASES OF THE CIRCULATORY SYSTEM. 



Jaundice — (possible). 
Spleen— enlarged. 

Urine — scanty, highly colored, and albuminous. 
Typhoid symptoms before death. 

Physical. 

Auscultation. — A hard regurgitant murmur is heard with the -first 
or second sound, coming on suddenly. 

PROGNOSIS. 

Usually fatal. Death may result in a few hours, or three to four 
days at most. 

CHRONIC ENDOCAEDITIS. 
DEFINITION. 

Is a parenchymatous inflammation, marked by thickening and 
induration of the endocardium (being of an acute origin) ; is prin- 
cipally found in the endocardial covering of the valves, and that 
portion lining the apex of the left ventricle. It occurs principally 
in persons of a rheumatic history. 

MORBID ANATOMY. 

The THICKENING — is the immediate result of the increase of 
connective-tissue. It is most marked at the base of the valves 
and along the line of contact. It may be very slight, or the valves 
may be so roughened, thickened, and hardened, as to impair or 
-entirely destroy their functional activity. 

The RETRACTION — is the result of the changes in the new con- 
nective-tissue formations, wherein it becomes of a fibroid charac- 
ter, causing rigidity, diminution in depth, and puckering of the 
valves. Their edges have a cartilaginous feel. I he changes 
are most marked in the mitral valves, being chiefly detected at 
the base of the valves, and around the valvular orifices; the edges 
of the valves are sometimes drawn down and become fastened to 
the walls of the ventricles by a short tendinous cord, causing 
extreme regurgitation. 



CHRONIC ENDOCARDITIS. 



115 



The adhesions— occur with the retractions; and commence at 
the edges of the valves (as above), and continue till all traces of 
the valves may be lost, producing the button-hole slit. This is 
usually confined to the mitral and aortic orifices. 

The degeneration of the valves. — After the cell - and new 
connective-tissue formation have gone on, and reached a certain 
point, fatty, granular, or calcareous degeneration takes place, 
forming under the endocardium patches of fatty, granular, or 
calcareous substance. These result occasionally in ulceration, and 
their removal is usually followed by extensive destruction of tis- 
sue, rupture of the valves, and regurgitation. Calcareous degener- 
ation is mostly in the aortic orifice, as the changes occur at a late 
period of life. 

These growths are not superficial, but an increase in the tissue 
underneath the endocardium, being sometimes half an inch or 
more in length. Thoy are termed vegetations, often cause sudden 
and fatal regurgitation. When separated from the valve, they give 
rise to emboli, and development of infarction, and death of some 
portion of the various vital organs. These vegetations are of a 
fibroid-tissue growth extending through the entire thickness of 
the cardiac walls, causing shortening, thickening, and contraction 
of the chordae tendineae and columnae carneae. They are due to 
inflammatory changes. 

SYMPTOMS. 

The manifestations of this condition are in the heart's sounds, 
indicating valvular changes. 

PROGNOSIS. 

Depends upon the seat, and extent of the valvular lesion. 
TREATMENT. 

Remove the cause. Remove your patient from all excitement 
and alcoholic stimulants. Protect the body from sudden exposure 
to temperature (see valvular lesions for further treatment). 



116 



DISEASES OF THE CIRCULATORY SYSTEM. 



VALVULAR LESIONS. 
These lesions are of two kinds. 

Mrsf.— Valvular thickenings, with slight retraction and ad- 
hesions, and atheromatous and calcareous degenerations; which 
give rise to murmurs, and cause obstruction to the current of the 
blood. 

Second. — Extensive valvular retraction, perforation, partial 
■detachment of the valves, rupture of the chordge tendineae, and 
calcareous plates, causing the valves not to close, and thus allow- 
ing of a return of the blood to the cavity, called ' insufficiency.''' 
These alterations may co-exist, one being more extensive than the 
other. 

AORTIC OBSTRUCTION". 
DEFINITION. 

An abnormal condition of the aortic valve, obstructing the 
escape of blood from the left ventricle into the aorta. It is always 
accompanied by hypertrophy of the left ventricular wall. 

MORBID ANATOMY. 

Changes take place in the aortic valves during acute and 
chronic endocarditis, as well as atheromatous degeneration of 
these valves; causing them to become thick and rigid, and to pro- 
trude into the current, thus producing a mm-mur with the first 
sound of the heart. There may be also vegetations on the surface 
of the thickened endocardium on the valves, obstructing the out- 
going current, or a development of calcareous plates underneath 
the valves, also producing obstruction (stenosis). All of these con- 
ditions involve the left ventricle, producing gradual hypertrophy 
of its walls (unattended by dilatation); and, after a time, insuffi- 
ciency of the mitral valves follows (due to extension of the endo- 
cardial inflammation). 



AORTIC OBSTRUCTION. 117 

ETIOLOGY. 

It occurs in middle or advanced life, from acute or chronic 
endocarditis; or, from prolonged and severe muscular exertion, 
and atheromatous degeneration of the aorta. 

SYMPTOMS. 
Rational. 

Pulse— small in volume, compressible, jerking, or intermittent. 
Syncope — (on account of cerebral anaemia) — may occur. 
Embolism of the brain (if the vegetations become detached and 
pass upward). 

(Edema ot the feet (from defective venous return) — may occur. 
Physical. 

Inspection. — The area of cardiac impulse is increased. 

Palpation. — The force of the heart is increased, and heaving; and 
the heart-beat is more to the left than normal. 

Percussion. — Increased area of dullness (to the left and downward) 

Auscultation. — There is a murmur with t\ie first sound, darQctlj 
over the aortic valve, behind the sternum at the junction of 
the third rib. The murmur is heard with the greatest intensity 
at the second costo-sternal articulation of the right side, and 
along the carotids. It may replace the first sound or follow it 
immediately. The murmur is harsh in character. 

DIFFERENTIAL DIAGNOSIS. 
Rests upon the presence of a systolic aortic murmur; it may be 
mistaken for mitral, tricuspid, aortic regurgitant, and anaemic 
bruit. 

Aortic obstructive. 

Is a systolic murmur, heard at the apex, and the anterior por- 
tion of the chest. The maximum of intensity is heard at the 
second costo-sternal articulation of the right side, and along 
the carotids. 

Mitral regurgitant. 

Is a systolic murmur heard at the base of the heart, with less 
intensity than at the apex. The maximum of intensity is 
heard at the apex, and carried round to the left. 



118 



DISEASES OF THE CIRCULATORY SYSTEM, 



Aortic obstructive. 

Maximum of intensity (see above). 
Tricuspid regurgitant. 

The maximum of intensity is heard at the apex, and is rarely 

audible above the third rib with the sternum. 
Aortic obstructive. 

Hypertroi3hy of the heart exists. Increased force of apex- 
beat, and jerky pulse may be detected. 
Ancemic bruit. 

Is heard over the carotids and is a venous hum. There is a 
feeble apex-beat; the pulse is soft, full, and compressible. 

PROGNOSIS. 

• If the rhythm of the heart is not destroyed, the chances as to 
duration of life are not bad ; otherwise they are, as the patient 
may die of cerebral anaemia, from the cutting off of the blood- 
supply. If the murmurs have lasted one or two years, you may 
be sure there are vegetations. 

TREATMENT. 
See "Aortic Regurgitation." 

AOETIO EEGUKGITATION". 
MORBID ANATOMY. 
This is one of the gravest forms of heart-disease. The semi- 
lunar valves may be shortened, or shrunken, by chronic endocar- 
ditis, preventing closure; or, there may be laceration, dilatation, 
or adherence, causing a free opening. The regurgitation causes 
over-distention of the left ventricle, producing dilatation of tliat 
cavity from relaxation of the muscular fibres; and hypertrophy of 
the left ventricle ensues, in order to resist, and overcome the 
obstruction to the circulation. Over-dilatation of the arteries also 
ensues from an abnormal quantity of blood being thrown into 
them. Endocarditis is developed; and degeneration of the arterial 
walls occurs, leading to the rupture of an artery, usually in the brain 
(in case of over-excitement or excessive exercise), and the symptoms 



AORTIC REGURGITATION. 



119 



of cerebral apoplexy. Tissue-degeneration of the heart also takes 
' place from diminished supply to the coronary vessels, through 
insufficiency of the aortic valves. Dilatation of the left ventricle 
recommences and progresses (extensively'; the mitral valves are 
not strong enough to close the auriculo-ventricular orifice, and 
regurgitation takes place through that orifice, on account of an 
extension of the endocarditis, atheromatous change, chronic endo- 
carditis, and shrinking or shortening of the chordae tendineae. 
Aortic regurgitation thus becomes modified, by failure of the 
mitral valves. There is a general dirturbance of the venous circu- 
lation, late in the disease, resulting -in cyanosis and dropsy. 

ETIOLOGY. 

Acute or chronic endocarditis ; bodily exertion ; atheroma of 
the aorta. 

SYMPTOMS. 
Rational. 

Palpitation of the heart — (which is not constant). 
Hypertrophy — sometimes excessive, producing excessive heart's 
action, vertigo, headache, syncope, and spots before the eyes. 
Pulse — quick, jerking, irregular, and intermittent. 
Radial pulse — a little after the apex-beat, in point of time. 
Dyspnoea — due to pulmonary congestion. 
Anaemia — excessive (due to emptiness of the arteries). 
Giddiness — (due to interference with the cerebral circulation). 
Increase in the carotid pulsation. 

Overloading of the veins (due to impaired return to the heart). 
Cyanosis (when the lungs are excessively congested). 
Dropsy (when the systemic circulation becomes impaired). 
Death (from cerebral embolism, disease of liver and kidneys, apo- 
plexy, failure of heart, general dropsy, etc). 

Physical, 

Inspection. — Increased area of the apex-beat, an(J carotid pulsation. 
Palpation.— YLQdiNing impulse about the 8th rib, and to the left 

of the left nipple. 
Percussion.— AxQ^ot precordial dullness is to the left of, and below 



120 



DISEASES OP THE CIRCULATORY SYSTEM. 



the normal area, and is more oval than normal ; as dilatation 
comes on, the dullness will extend upward, and the apex-beat 
may be perceived as high up as the axillary space. 
Auscultation. — A murmur is heard with the second-sound, some- 
times immediately following it ; maximum intensity over the 
second intercostal space close to the right edge of the sternum 
over a large area, or down to the xyphoid cartilage, or, along 
the spine. It is heard, as a diastolic murmur, at the base of 
the heart ; when combined with aortic obstruction, there is a 
double murmur heard over a large area, at the second inter- 
costal space to the right, or left of the sternum. 

DIFFERENTIAL DIAGNOSIS. 
Rests on the diastohc murmur, and the presence of hypertrophy 
and dilatation. It can only be confounded with mitral stenosis 
(which has no hypertrophy, nor dilatation of the left ventri- 
cle). In pericarditis (confined to that portion above the aorta), a 
friction-sound resembling the murmur may be heard, but this 
occurs only during diastole, and without evidences of either 
hypertrophy or dilatation. 

PROGNOSIS. 

It depends on the age of the patient. It is exceedingly unfa- 
vorable when occurring in those of middle age, especially if they 
are engaged in active pursuits. The dangers are hypertrophy of 
the left ventricle, augmenting the distended force of the arterial 
walls, causing degeneration ; degeneration of the hypertrophied 
ventricular walls, from impaired nutrition, on account of inter- 
ference of the coronary circulation, causing excessive dilatation 
and weakening of the heart ; and an inability of the heart to over- 
come the resistance, resulting in cyanosis, dropsy, and death. In 
old people, it gives rise to very little inconvenience. 

CAUSES OF DEATH. 
From hypertrophy and degeneration of the ventricular walls ; 
from cerebral embolism; from regurgitation, accompanied by vege- 
tations on the valves ; from obstruction to the systemic circula- 
tion (producing sclerosis of the liver and kidneys) ; from pul- 



MITRA.L OBSTRUCTION. 



121 



monary oedema ; cerebral apoplexy ; or from sudden syncope 
(from obstruction to the return circulation). 

TREATMENT. 

Absolute rest is imperative. There must be avoidance of all 
physical and mental exercise, or intemperance in any form. The 
patient must have a nutritious diet, chiefly albuminous. Care 
must be taken not to disturb the heart's action. The patient must 
lead a quiet life. Digitalis should never be resorted to in this 
disease. Iron should be administered if there are symptoms of 
imperfect heart-power, and anaemia be present. For the relief of 
dyspnoea and dropsy, see mitral regurgitation." 

MITRAL OBSTRUCTION. 
DEFINITION. 

Is a condition of stenosis, or obstruction, of the auriculo-ven- 
tricular orifice of the left heart ; and is due partly to constriction 
at the base of the mitral valves, and partly to adhesion of the 
valve-tips and chordae tendineae, following rheumatic endocar- 
ditis (it occurs principally in young children). 

MORBID ANATOMY. 
The new connective-tissue, by contracting, causes obstruction 
to the flow of the blood from the auricles to the ventricles, by pro- 
ducing incomplete opening of the auriculo -ventricular orifice. 
In stenosis, the edges of the valves become adherent, as may also 
the chordae tendineae, forming the " button-hole slit" (the normal 
opening should easily admit the ends of three fingers). Dilabation 
and hypertrophy of the left auricle are thus produced from its over- 
distention; also obstruction in the pulmonary veins, and dilatation 
of tlie pulmonary capillaries, causing congestion of the pulmonic 
circulation, or pulmonary congestion. The lungs may be found 
to be in a state of pigmentation (" brown induration"). Bronchor- 
rhoea may also occur, due to hyperaemia of the bronchial mucous 
membrane; and pulmonary apoplexy may even occur from rupture 
of the pulmonary blood-vessels. This latter complication may be 



122 



DISEASES OF THE CIRCULATORY SYSTEM. 



caused by exercise, since the pulmonary hypersemia is thus 
increased. Pnlmonary oedema may be readily developed when 
this valvular disease is strongly marked, from walking against a 
strong head- wind ; and may result in death. 

ETIOLOGY. 

Mitral obstruction may be the result of acute or chronic endo- 
carditis, in young people ; and of all the morbid changes in the 
blood ; such as Bright's disease (from the irritation p reduced by 
urea in the circulation) ; acute articular rheumatism ; sometimes 
of changes in the salts ; or poisons, acting as an irritant to the 
valves (as in diphtheria, septicaemia, pyaemia, and all the fevers). 

SYMPTOMS. 
Rational. 

Dyspnoea — (a result of the pulmonary congestion). 

Cough — dry, hacking, unsatisfactory ; resembles a nervous cough; 

is due to changes in the lungs (congestion^ not to the heart. 
Haemoptysis — of dark color, usuallyslight in amount. 
Expectoration — profuse, watery, and blood-stained (especially 

after exertion) — this denotes puhnonrr - congestion. 
Pulse — regular (if the ventricle be not affected, and only a slight 

stenosis exist) : but may be feeble (if stenosis be extensive). 

Physical. 
Inspection. — Feeble cardiac impulse. 

Palpation. — A distinct purring thrill preceaes the apex-beat. 

Percussion. — Area of dullness increased upward, and to the left. 

Auscultation. — A loud blubbering murmur is heard, just before 
the first sound ; and is synchronous with the contraction of 
the auricle. The maximum of intensity is heard a little above 
the apex-beat; is louder and longer than any other murmm". 

DIFFERENTIAL DIAGNOSIS. 
Depends upon the loud blubbering murmur, and the purring 
thrill. It is a presystolic murmur. It may be confounded with 
mitral and aortic regurgitation. 



MITRAL REGURGITATION. 



123 



PROGNOSIS. 
Is bad, especially if excessive dyspnoea be present. 

TREATMENT. 
Same. as in mitral regurgitation (see page 126). 

MITRAL REGURGITATION. 
DEFINITION. 

Is caused by thickening, induration, and shortening of the 
mitral valve ; due to changes produced by acute or chronic endo- 
carditis. It is the most common valvular lesion. 

MORBID ANATOMY. 

The regurgitation is often caused by calcareous matter imbedded 
in the valves. The chordae tendinese become thick and short, and 
the papiUary muscles (which aro the terminations of the chordae 
tendinese) become diminished in bulk. The valves may be torn, 
the chordae tendinese ruptured, and the regurgitant current then 
causes them to flap ; or the valves may become adherent to the 
ventricular walls through shortening of the chordae tendineae. 
The following changes take place in consequence : 
1st. — Dilatation of the left auricle (as a result of excessive blood- 
pressure). 

2d. —Compensatory hypertrophy of the left auricle (to increase its 
power, and thus to force blood through the narrowed orifice). 

3d. — Disturbed pulmonary circulation, producing congestion or 
brown induration (when the previous hypertrophy proves 
insufficient). 

'ith.— Hypertrophy of the right ventricle (to overcome pulmonary 
obstruction). 

5th. — Dilatation of the right ventricle (as the result of too great 
pressure). 

6th. — Tricuspid regurgitation (due to an endocarditis excited, or 
to excessive dilatation of the ventricle). 



124 



DISEASES OP THE CIRCULATORY SYSTEM. 



7th. — Dilatation of the right auricle (from the pressure of the 

regurgitated blood). 
8th. — Compensatory hypertrophy of the right auricle (to overcome 

the previous dilatation). 
9th. — Interference to the return circulation of the venous blood 
from the superior and inferior venae cavae. 
In superior vena cava. 

Producing, headache ; vertigo ; jugular pulsation ; promi- 
nent jugulars ; cyanosis ; oedema ; apoplexy ; etc. 
In inferior vena cava. 

Producing, nutmeg-liver ; obstruction to the portal cir- 
culation ; hemorrhoids ; menstrual disturbance ; gastric 
catarrh ; epigastric pulsation (which is hepatic, from re- 
gurgitation into its vessels) ; intestinal catarrh ; ascites ; 
jaundice ; enlarged spleen ; passive hypergemia of the 
kidney, or desquamative nephritis (catarrhal); and general 
anasarca. 

In order to overco^ne these changes and keep up the heart's 
power, hypertrophy and dilatation of the left ventricle finally 
take place. 

ETIOLOGY. 

Primary cause. 

Acute endocarditis. 

It may he secondary to 

some lesion of the aortic valves, either from extension of the 
endocardial inflammation or to a valvulitis excited by the re- 
gurgitant current from the aorta. Enlargement of the left 
auriculo- ventricular orifice, which accompanies excessive dila- 
tation of the left ventricle, may produce it. 

SYMPTOMS. 
Rational. 

Are chiefly due to the regurgitation at the tricuspid orifice— and 
are therefore developed late in the disease. 

Cough— with watery expectoration which is sometimes stained 
with dark or blackish blood (a symptom of pulmonary dropsy). 



MITRAL REGURGITATION. 



135 



Enlarged liver (due to interference with its return of blood). 
Pain and weight in the right hypochondrium (from hyperaemia). 
Jaundiced hue to the surface. 

Cyanosis — (a symptom of impaired venous return). 

Cerebral hypersemia. 

JSeadache — due to hyperaemia of brain. 

Vertigo— duo to hyperaemia of brain. 

Stupor — due to hyperaemia of brain. 

Delirium (temporary). 

Gastric and intestinal catarrh — due to hyperaemia. 
Hemorrhoids — due to hyperaemia. 
Amenorrhoea— due to hyperaemia. 
Urine — scanty, high-colored, and casts. 

Rapid ascites -produced by a sero-albuminous exudation through 
the walls of the vessels; commencing in the lower part of the 
abdomen and extending upward. 

General anasarca (beginning at the ankles and extending upward). 

Irregular radial pulse— being at first exceedingly feeble, compress- 
ible, and tremulous on excitement. 

Physical. 

Inspection and Palpation. — Increased area of cardiac impulse, 
which may be forcible, or diffused; depending upon the 
amount of hypertrophy and dilatation. Apex-beat is more 
to the left than normaL 

Percussion. — Precordial dullness increased, extenduig to the left 
beyond the nipple and downward; showing more or less 
hypertrophy and dilatation. Area of superficial dullness is 
increased laterally amd downward. 

Auscidtation.—K murmur takes the place of, or follows, the first 
sound, and is synchronous with the systole of the ventricle, 
and due to regurgitation from the left ventricle to the auricle. 

Diagnostic points. 

Its greatest intensity is at the apex-beat. Area of diffusion is 
to the left, and it is heard with nearly the same intensity 
behind, between the fifth and eighth dorsal vertebrae, 
close to the left side of the spinal column. The second 



126 



DISEASES OF THE CIRCULATORY SYSTEM. 



sound is abnormally intense over the pulmonic valves 
a little above the third rib. 

CAUSES OF DEATH. 
CEdema of the lungs, on account of the feeble and irregular 
heart action; hemorrhagic infarction (from pneumonia), the in- 
flammation causing death; general anasarca; or Bright's disease. 

DIFFERENTIAL DIAGNOSIS. 
From aortic regurgitation and obstruction, and tricuspid regur- 
gitation; but the murmur, area of diffusion, and character of the 
pulse, are sufficient to enable you to make a satisfactory diagnosis. 

In mitral regurgitation— the pulse is feeble and easily acceler- 
.^ted. 

In aortic regurgitation — the pulse is hard and jerky. 

In mitral regurgitation — the murmur occurs with the first 
sound, is heard at the apex and carried to the left and backward 
between the fifth and eighth dorsal vertebrae. 

Aortic obstruction — occurs with the first sound and is conveyed 
along the carotids. 

Tricuspid regurgitation — occurs with the first sound and is 
heard over the right ventricle and to the right of the area of the 
heart. 

PROGNOSIS. 

As far as the duration of life is concerned, the prognosis is 
good, on account of compensating hypertrophy and the stationary 
character of the exciting cause. If oedema, cyanosis, extreme 
dyspnoea, etc. , be present, the prognosis is bad. 

TREATMENT. 

The patient must lead a quiet life, free from all excitement ; 
and have absolute self-control. A change of occupation may 
become necessary, if there be a predisposition to pulmonary 
hypertrophy or bronchial catarrh. Forbid the use of the voice, 
as in singing, etc., as there is a constant pulmonary hj'-pera^mia, 
which such acts tend to increase. If excessive pulmonary cedema 
occur, venesection or hydragogue cathartics shoald be res(irt<,\l 



PULMONIC REGURGITATION. 



127 



to. Give Inf. Digitalis 1 ss. every two hours for twenty-four 
ho\irs; it relieves the hypersemia and favors systemic circulation; 
it regulates and increases the systolic action, by its action on the 
muscles of the heart; it strengthens the right heart and enables 
the left ventricle to resist the increasing dilatation. It should not 
he continuously employed, but only for twenty-four or forty-eight 
hours, if good results be obtained. If it be judiciously used, it 
may cause disappearance of the pulmonary oedema, cyanosis, 
anasarca, and scanty urine. 

Iron may be given with the food in full doses, but only in cases 
of ansemia (Vallet's Mass gr. x.-xx t. i. d.) 



VALVULAR DISEASES OF THE RIGHT HEART. 

These are all secondary to those of the left heart, and are very 
rare, as endocarditis seldom occurs on that side. When endocar- 
ditis does occur on the right side, it is usually confined to the 
tricuspid valve; and is due to obstruction in the pulmonic 
circulation from disease of the mitral valve, which induces an 
hypertrophy of the right ventricle and subsequent valvular 
lesions. 

PULMONIC VALVES. 

PULMONIC OBSTRUCTION OR STENOSIS. 

Is usually caused by mediastinal tumors pressing on the pul- 
monary artery, diminishing its calibre and obstructing the 
current. The murmur occurs with the first sound, and the 
maximum of intensity is over the seat of the valve. The 
murmur is superficial and distinct, and the area of diffusion is 
toward the left shoulder. 

PULMONIC REGURGITATION 

Is doubted by many eminent physicians, if this condition exist 
to such an extent as to constitute a pathological lesion. Tlie 



128 



DISEASES OF THE CIRCULATORY SYSTEM. 



murmur occurs with the second sound, over the pulmonic valves; 
and the area of diffusion is carried down to the xiphoid cartilage. 
There is no jerking or pulsation as in aortic regurgitation. 

PROGNOSIS. 

Is theoretically bad. If it occur as a primary disease, it causes 
dilatation of the right ventricle, tricuspid regurgitation, and 
disturbance of the systemic circulation. 



TRICUSPID REGURGITATION. 
DEFINITION. 

Is usually secondary to mitral stenosis or regurgitation. It is 
preceded, as a rule, by hypertrophy of the right ventricle, since 
pulmonic obstruction has to be overcome. 

MOEBID ANATOMY. 
There is thickening and shrinking of the valves; shortening of 
the chordae tendineae; and more or less thickening and induration 
at the base of the valves, thus diminishing their size. There is 
first dilatation and, secondly, a compensatory hypertrophy of the 
right auricle; there is disturbance in the circulation of the venje 
cavas, as shown under the description of morbid changes' due to 
mitral regurgitation (page 123); last of all, the left ventricle becomes 
involved, on account of the increased work of the left heart from 
the systemic obstruction. 

ETIOLOGY. 

Its spontaneous occurrence is doubtful; pulmonary emphysema 
causing interference with the pulmonary circulation and subse- 
quent endocardial inflammation, from abnormal stress thrown on 
the valves at the auriculo-ventricular orifice, may produce it; and 
also interference with the pulmonary circulation from any cause, 
as mitral lesions, mediastinal tumors pressing upon the puhnonary 
artery, etc. 



TRICUSPID REGURGITATION. 



1^9 



SYMPTOMS. 
Rational.* 

When the venous return is interfered with, there may he 
Enlarged liver — (due to venous engorgement) — nutmeg liver. 
Dinginess on the surface of the body. 
Urine— scanty. 

Bright's disease (from passive hypersemia of the kidney). 
Headache (from passive hypersemia of the brain). 
Vertigo (from passive hyperaemia of the brain). 
Dementia (from passive hyperaemia of the brain). 
Irregular heart's action. 
Cardiac palpitation. 

Dyspnoea (from passive hyperaemia of the lung). 
Face — blue and turgid; with stupor, coma, and cerebral com- 
pression, if the patient be placed in a horizontal position. 
Physical. 

Inspection. — Increase in the visible cardiac impulse from the apex- 
beat to the xiphoid cartilage and to the second intercostal 
space. Pulsation in jugulars. Distended jugulars. 

Palpation. — Indistinct apex-beat, unless hypertrophy of the left 
ventricle exist. Epigastric pulsation. 

Percussion. — Area of dullness is increased to the right of the 
sternum and to the second intercostal space. 

Auscidtation. — There is a blowing murmur taking the place of the 
first sound. It is superficial andi rarely heard above the third 
rib. The maximum of intensity is between the fourth and 
and sixth ribs at the left border of the sternum. The second 
sound is increased in intensity, and heard most distinctly 
over the pulmonic valve. 

DIFFERENTIAL DIAGNOSIS. 
From mitral regurgitation ; aortic obstmction ; and pulmonic 
obstmction. 

* For the explanation of these symptoms see page 124 of this volume. 



130 



DISEASES OF THE CIRCULATORY SYSTEM. 



PROGNOSIS 

Is bad (see page 124 of this volume, where dangers, due to 
venous engorgement, are given in some detail). 

TREATMENT. 

The patient must lead a quiet life, and reside in a warm climate; 
where a free action of the skin can be maintained. When it 
occurs in connection with emphysema, digitalis is not well borne, 
as it increases tlie jugular pulsation and distends the veins of the 
head and neck, but. sliould it occur in connection with mitral 
regurgitation, digitalis is then of great service. Iron must be 
administered, if anaemia exist (as mentioned under the treatment 
of mitral regargitatian). Drastic cathartics temporarily relieve 
the venous engorgement and cerebral oppression, but, should 
anasarca be developed, incision or needle pricking is the only 
means of relief. 



CARDIAC MURMURS. 
Rhythm of Murmur. 

Is the relaXion of the murmur to the sounds of the heart. 
Heart-Sounds. 

First sound.— Is distinguished by the striking of the apex of 
the heart against the chest-wall, and is synchronous with the 
radial pulse. It is longer in point of duration than the second 
sound, since it is due to the continued effect of four causes, as 
follows: (1) The blow of the apex upon tlie chest-wall; (2) the 
friction of the muscular fibres of the ventricles: (3) the rush 
of blood in the ventricles; (4) the closure of the auricrJo- ven- 
tricular walls. Should there be a murmur it will bear the 
same relation to the apex-beat and radial pulse as the first 
sound does. 

Second sound.— Is distinguished by a short, sharp sound which 
is produced by closure of the aortic and pulmonic valves. 
All munnnrs either precede, take the place of, or follow immedi- 
ately one of the sounds of the heart. 



CARDIAC MURMURS. 



131 



Presystolic Murmurs. 

Mitral obstructive. — Is heard with greatest intensity over a cir- 
cumscribed space at the apex. It is characterized by a pwr- 
ring sound, and is the loudest and longest of all the murmurs. 

Tricuspid obstructive. — Is heard with greatest intensity along the 
margin of the fifth and sixth costal cartilages, on the left 
border of the sternum. Its area of diffusion is over the right 
ventricle and rarely above the third rib. 

Systolic Murmurs. 

Mitral regurgitant. — Is heard with greatest intensity at the apex. 
Its area of diffusion is carried to the left, and is often heard 
between the fifth and eighth dorsal vertebrae or at the angle 
of the scapula. 

Tricuspid regurgitant. — Is heard with greatest intensity between 
the fifth and sixth ribs along the sternum. Its area of diffu- 
sion is over the right ventricle and rarely above the third rib. 
It is a loud blowing murmur. 

Aortic obstructive. —Is heard with greatest intensity at the second 
costo-sternal articulation of the right side. Its area of diffu- 
sion is upward along the carotids. Inaudible at the apex. 

Pulmonic obstructive. — Is heard with greatest intensity over the 
seat of the valves at the junction of the third rib and sternum 
of the left side. Its area of diffusion is carried toward the 
left shoulder. 

Diastolic Murmurs. 

Aortic regurgitant. — Is heard with greatest intensity at the 
third costo-sternal articulation on the right side. Its area of 
diffusion is carried doivn the sternum to the xiphoid appendix, 
and it may be heard at the apex. 

Pulmonic regurgitant. — Is heard with greatest intensity over 
the seat of the valve, at the junction of the third rib and the 
sternum of the left side, and is carried down to the apex. 
In addition to the above-mentioned murmurs there may also be 

Ancemic murmurs— heard with greatest intensity in the carotids. 

Ventral murmurs— are produced within the left ventricle from 
roughening of the chordae tendineae, or the ventricular sur- 



/ 



132 DISEASES OF THE CIRCULATORY SYSTEM. 

face of the mitral valves, or bv an abnormal direction to the 
current of blood as it passes through the ventricle. These are 
very rare. 

CAEDIAC HYPERTEOPHY. 
DEFINITION. 

Is the result of overwork, and consists of a thickening of the 
walls of the heart by an increase in the muscular tissue, involving 
both the auricles and the ventricles, or either one alone. 

VAEIETIES. 

Simple — ^where there is thickening of the walls, but no increase 
in the capacity of the cavities ; it is confined to the left ventricle 
(occurs in Bright's disease and alcoholism). 

Eccentric — where there is thickening of the walls, and increase 
in the capacity of the cavities (occurs with valvular lesions). 

Concentric — where there is thickening of the waUs, but diminu- 
tion in the capacity of the cavities ; this is of very rare occurence. 

MORBID ANATOMY. 
In the eccentric form. — There is an increase in the size of the 
papillary muscles, and thickening of the septum, A change takes 
place in the shape of the organ, which con-esponds with the seat 
of the hypertrophy. If the hypertrophy be confined to the left 
ventricle, the heart will be of a- p^ndform shape : if to the right 
ventricle, there is an increase in the horizontal measm-ement, 
making it oval and elongated. The walls of the heart are stiffened, 
and do not coUapse when opened after death : and are redder 
than normal. Hypertrophy is simply a h^-per^^lasia. Tliere may 
be an increase in the size of the muscular fibres, but the hyper- 
trophy chiefly consists in an increase in theii' number. The heart 
may weigh 40 ounces more than norjnal. 

ETIOLOGY. 

It seldom exists viithout valvtilar lesions, arterial changes, or 
capillary obstruction. Anything which tends to create dilatation 
of the heart cavities or mechanical obstmction to the circulation 
of blood may produce it. 



CARDIAC HYPERTROPHY. 



133 



SYMPTOMS. 
Rational. 

In Moderate Cases. 

Fullness of the arteries. 

Emptiness of the veins. 

Pulse — full and strong. 

Face — easily flushed ; and eyes brilliant. 

Carotid pulsation. 
In Severe Cases. 

A sense of fullness in the chest, from pressure of the enlarged 
heart. 

Uneasiness — in the epigastric region — from pressure. 
Impaired digestion — from pressure. 
Dyspnoea — from pressure on the lung. 
Cardiac palpitation— under excitement. 
Headache — when under excitement. 
Vertigo— when under excitement. 
Tinnitus aurium — when under excitement. 
Atheroma — from extension of the endocarditis. 
Endarteritis — from extension of the endocarditis (causing 
changes in the coats of the vessels). 

Physical. 

Inspection. — Increased and distinct area of impulse, and visible 
motion of the chest on cardiac pulsation. In children — bulg- 
ing of the precordial space, and displaced apex-beat. 

Palpation. — Increased area of apex-beat and the detection of a 
heaving, lifting character over the whole precordial space; 
which determines hypertrophy of the left ventricle. If hyper- 
trophy of the right ventricle exist, there will be a strong 
epigastric pulsation. If hypertrophy of the left ventricle 
exist, the apex-beat will be to the left (three inches below and 
two or three inches to the left of the nipple). In eccentric 
hypertrophy .—li the right ventricle be affected, the apex-beat 
is to the right and downward. If the left ventricle be affected, 
the apex-beat is to the left and downward. 

Percussion. — Dullness is increased to tlie right, or left, or down- 
ward ; and when upward the auricles are hypertrophied and 



134 



DISEASES OF THE CIRCULATORY SYSTEM. 



dilated, but it is rare. If hypertrophy of the right ventricle 
exist, there is dullness to the right of the sternum. If hyper- 
trophy of the left ventricle exist, there is dullness to the left 
beyond the nipple. If eccentric — the dullness is increased in 
both directions. 

Auscultation.— The first sound (if no murmur be detected) will be 
dull, muffled, and prolonged, with increased intensity. The 
second sound is increased in intensity in both hypertrophy of 
the left and right ventricle. If there be hypertrophy of the left 
ventricle, it is heard with greatest intensity over the aortic ori- 
fice; if there be hypertrophy of the right ventricle, it is heard 
with greatest intensity over the pulmonic orifice. There is 
absence of the respiratory murmur over the precordial space. 
In emphysema, there may not be much increase of force in the 
apex-beat; the heart's sounds will be diminished; and a venous 
pulsation in the neck (due to hypertrophy and dilatation of 
the right ventricle with tricuspid regurgitation) may be per- 
ceived. 

DIFFERENTIAL DIAGNOSIS. 

In eccentric hypertrophy of the left ventricle. — The pulse will be 
full and strong; there will be carotid pulsation, the countenance 
flushed; the eyes prominent and brilliant; the apex-beat forcible, 
over an unnatural area, and carried to the left; the cardiac dull- 
ness increased to the left and downward; and there will be in. 
creased intensity of heart's sounds, especially of the second sound. 

In eccentric hypertrophy of the right ventricle, there will be 
forcible heart's action noticed along the sternum and left lobe of 
the liver; the apex-beat is carried to the right and downward; the 
cardiac impulse is nearer the median line; there is somewhat of 
an epigastric impidse, increased area of dullness to the right; and 
the pulmonic sounds are increased. The first sound is more 
intense than normal and nearer the median line. 

In total eccentric hypertrophy. — Everything is the same as in 
hypertrophy of the left ventricle, except that the dullness is in- 
creased in all directions, and the heart's sounds are more intense 
than normal. 



CARDIAC DILATATION. 



135 



The condition of hypertrophy is to be further differentiated from 
cardiac dilatation ; thoracic aneurism ; mediastinal tumors ; con- 
sohdation of the lung-tissue ; and pleuritic effusions. 

PROGNOSIS. 

Is more favorable than in any other cardiac affection; simple 
hypertrophy (unless from aortic stenosis) may exist for years; 
slight hypertrophy is very common; if degeneration of the hyper- 
trophied walls exist, the prognosis is very unfavorable. When 
hypertrophy of the right ventricle is accompanied by pulmonary 
obstruction, the prognosis is bad. 

TREATMENT. 

Alcoholic stimulants, immoderate eating, active and prolonged 
physical and mental exercise, must be strenuously avoided. All 
obstructions to the abdominal circulation must be removed. The 
bowels should be made to move freely, by regulating the diet so 
as to prevent constipation and straining. If cerebral symptoms 
occur, they should be overcome by aconite in full doses. Fleming's 
tincture of the root, gtt. ij.-iij. may be given every three or four 
hours, but should the dilatation exceed the hypertrophy, do not 
give it. Digitalis should only be administered when the heart's 
action is enfeebled. 

OAEDIAO DILATATION. 
DEFINITION. 

A condition which is characterized by an increase in the capacity 
of its cavities, and a diminution in its contractile power. 

VARIETIES. 

Simple — Where there is an increased capacity of the- cavities ' 
and no marked change in the walls; it occurs in convalescence 
"from typhoid fever, or any disease where there has been great 
impairment of nutrition. 

Hypertrophous — Where there is an increased capacity of the 
cavity; increased thickness of the heart- walls; and diminished 
contractile power. 



136 



DISEASES OF THE CIRCULATORY SYSTEM. 



Atrophic — Where there is a marked increase in the capacity of 
the cavities; the cardiac walls are thinner than normal; the 
ventricular walls diminished to two or three lines, and the auri- 
cles are almost transparent. 

MORBID ANATOMY. 
This condition may occur in one or all the cavities. The heart 
will be altered in shape, and this will depend upon where the 
seat of dilatation is situated. It occurs most frequently in the 
auricles; next in the right ventricle; and lastly in the left ven- 
tricle. If the walls of the left ventricle be very much thinned, 
they collapse when the ventricle is cut. A heart that is distended 
with blood and relaxed by putrefaction may be easily mistaken 
for a dilated heart; but, in such instances, the heart is extremely 
soft and saturated with the coloring matter of the blood, and 
there will be evidences of decomposition in other parts of the 
body. 

ETIOLOGY. 

Fi7}st cause — From internal pressure during cardiac diastole; 
from weakness, as the result of prolonged disease; from fatty 
degeneration; from abnormal pressure, producing permanent 
dilatation of its cavities; from degeneration, and an absence of 
compensatory hypertrophy. 

Second Cause. — From loss of tone when the muscular tissue of 
the heart is the seat of primary fatty degeneration; as occurs 
when there is first dilatation of the cavities with excessive blood- 
pressure, and after myocarditis. 

Third Cause. — From degeneration of muscular substance of the 
heart, which is the seat of eccentric hypertrophy (9ccurring after 
valvular diseases). * 
SYMPTOMS. 

RATIONAL. 

In simple dilatation. 

The cavities are increased, and labored heart's action exists. 
No increase in the heart's force. 
Feeble radial pulse. 
Rhythm not disturbed. 



CARDIAC DILATATION. 



137 



In atrophic dilatation. 

TJie cavities are dilated and thirmed. 

Labored heart-action and feeble power. 

Marked feebleness of the radial pulse. 

Heart staggers — from increased amount of blood. 

Arteries— imperfectly filled. 

Veins — distended and engorged. 

Jjisturbed rhythm. 

Radial pulse — is weak and intermittent. 
Common symptoms. 

Cardiac palpitation — severe, and distressing syncope. 
Constant and painful sense of pulsation of the heart. 
Dyspnoea — on slight exertion (which is constant in bad forms 

of this condition). 
Countenance — pale, languid, and anxious. 
Lips — livid, even when the patient is quiet. 
On excitement. 

Face and neck are livid. 

Pulse— irregular and intermittent. 

Loss of mental powers. 

Dyspeptic symptoms. 

Fullness in the epigastrium. 
Urine — scanty and albuminous. 

CEdema — causing the patient to sit up with the head forward, 

and resting on some support. 
Cyanosis — (when extensively developed). 
Yellow tinge of the surface — from disturbance of the liver. 
Delirium — (a late symptom). 

Death — from syncope, anasarca, or pulmonary oedema 
Physical. 

Inspection. — Indistinct and increased area of impulse, (especi- 
ally in fat or oedematous people). Uyidulathig movement 
over the precordial space (in thin subjects). No prom- 
inence of the precordial region. Irregular and distended 
jugulars (if the right heart be distended). 

Palpation.— Feeble cardiac impulse; absence of the lifting, 
forcible impulse, as in hypertrophy. Apex-heat is dif- 



138 DISEASES OF THE CIRCULATORY SYSTEM. 

fused, undulating, wanting in power, and resembling a 
feeble step. Purring thrill with the apex-beat like mitral 
stenosis, if mitral regurgitation co-exist. 

Percussion. — Increased dullness laterally (one inch to the right, 
if the right side be involved; or one inch to the left, if the 
left side be involved, often extending into the axillary 
space). The precordial dullness is omZ in shape. The 
area of superficial didlness is not increased, as in hyper- 
trophy. If the auricles be dilated, an upward increase 
in the area of dullness exists. If the jugular veins be 
permanently knotted, and dilated, there is dilatation of 
the right auricle. 

Auscultation. — The first and second sounds are short, feeble, 
and nearly of equal duration; and the second sound is 
often inaudible at the apex-beat. Asystolism is often 
present after exercise. 

DIFFERENTIAL DIAGNOSIS. 

Rests upon the feeble action ; undulating impulse ; indistinct 
apex-beat ; lateral increase in the area of percussion dullness ; 
short, abrupt, feeble heart's sound ; feeble, irregular, and inter- 
mittent pulse ; and the general symptoms of systemic and pul- 
monic obstruction. 

The differentiation must be made between cardiac hypertrophy 
and cardiac dilatation ; pericarditis with effusion, and cardiac 
dilatation ; enlargement from dilatation or hypertrophy, in con- 
nection with thoracic aneurism or mediastinal tumors. 

In thoracic aneurism or mediastinal tumors — there is the 
direction of the increased area of dullness to assist, since it is 
always upward, and to the right or left. 

In cardiac enlargement - there is increased area of dullness, 
laterally, .and dowmvard. Consolidation of lung-tissue may give 
rise to some of the signs of cardiac enlargement. 

PROGNOSIS. 

Is bad, and the danger increased in proportion to the excess of 
the capacity of the cavities over the thickness of their walls. 
There is danger of death from dyspnoea and syncope. 



MYOCARDITIS. 



131^ 



TREATMENT. 

This is an incurable disease. In order to prevent flaccidity of , 
the walls of the heart, nutrition must be kept up to 'its highest 
point by a milk diet and stimulants; and, if there be anasmia, 
administer iron. Plenty of fresh air, the best possible hygienic 
surroundings and stimulating baths, to increase the capillary 
circulation, should be afforded. All irregular and violent exercise 
must be forbidden; flannels must be worn next to the skin; arrest 
all exhausting discharges; and, as the various complications in 
the liver and other abdominal organs arise, they must be treated 
separately. If there be loss of appetite, etc. , give vegetable tonics 
and mineral acids. Digitalis is very serviceable in this disease in 
full doses, but if it cannot control the heart's action, then hella- 
donna and opium should be given in combination with digitalis. 

In the paroxysms of dyspnoea, hydrocyanic acid, cannabis^ 
indica, or ether may be given; and dry cupping along the spine. 
The drugs and treatment upon which most reliance can be placed 
are digitalis and iron, and a good wholesome nutritious diet. 

MYOCARDITIS. 
DEFINITION. 

Is an inflammation of the muscular structure of the heart; 
associated with degeneration and softening, which may be of two 
varieties: 

1. General ov diffused — which is rare. 

2. Local or circumscribed — which is met with in connection 
with pericarditis and endocarditis; usually involving only the 
internal or external surface of the heart. 

MORBID ANATOMY. 
The left ventricle is most frequently affected; the muscles 
changing from dark-red to gray, and finally to dark-green. It 
terminates either in a connective-tissue formation, or in abscess. 
The connective-tissue causes the power of resistance of the 
ventricular wall to be diminished. This connective-tissue, during 
diastole is gradually and slowly stretched; and thus, finally, 



140 



DISEASES OF THE CIRCULATORY SYSTEM. 



aneurism of the heart results. When the inflammatory process 
.becomes degenerative, abscesses form, and rupture of the heart 
may take place. 

ETIOLOGY. 
Predisposing Causes. 
Rheumatism— terminating in connective-tissue formation, 
Endocarditis. 
* Syphilis. 

Temperature — which must be high and continuously so. 
Extensive, and long continued, pericarditis. 

Exciting Causes. 
Embolism of the coronary arteries. 
Pyaemia (terminating in abscess). 
Septicagmia. 
Typhus fever. 
Typhoid fever. 

SYMPTOMS. 
Rational. 

Cardiac palpitation, and pain in the xDrecordial region. 
Pulse — feeble, irregular, and intermittent. 
Syncope — on exertion. 
Failure of the heart's action. 

Physical. 

Palpation.— The area of the precordial dullness is increased 
upward and toward the left shoulder, as in hypertrophy, but 
there is no heaving impulse. 

PROGNOSIS 

Is rapidly fatal if abscess occur; more slowly so, if the new 
connective-tissue formation is prominently developed. 

TREATMENT. 

Absolute quiet should be enforced, and the nutrition carried to 
its highest point. AU active and prolonged physical exertion 
must be prohibited. 



PATTY DEGENERATION OP THE HEART. 141 



FATTY DEGENERATION OF THE HEART. 
DEFINITION. 

True fatty degeneration of this organ is a substitution of fatty 
matter in place of the muscular tissue of the heart, to such an ex- 
tent as to interfere with its normal action. 

VARIETIES. 

1st. There may De a fatty degeneration of the primitive mus- 
cular fibre (Quain's). 

2d. There is a fatty deposit in the areolar or connective- tissue of 
the heart which is simply replaced by fat, the muscular fibres be- 
ing unaffected. 

MORBID ANATOMY. 

" In Quain's fatty degeneration " — the degeneration is confined 
to the muscular fibre, the primitive fibre-bundles lose their 
nuclei, their striated appearance disappears, and they become 
granular. The sarcolemma becomes filled with granules, and the 
sarcous substance gives place to fat-granules and oil-globules. 
The muscular-tissue assumes a yellow or dirty-brown color, and 
breaks down very easily under pressure. The coronary arteries 
may be atheromatous, calcified, obliterated, or normal. 

In the second form— there may simply be an increase of fat in 
the areolar tissue of the heart which does not interfere with the 
condition of the muscular fibre, except by its pressure; hence the 
heart is simply fiabby, pale, or yellowish, and may be more bulky 
than usual. 

ETIOLOGY. 

It may be a true fatty metamorphosis, due to interference of the 
heart's nutrition; or, secondly, an adipose condition of the heart 
due to an excess of fat in the blood (although this is not, properly 
speaking, a degenerative lesion). 



142 



DISEASES OF THE CIRCULATORY SYSTEM. 



Predisposing Causes. 

(1) Malnutrition, and interference with the coronary arteries. 

(2) Excessive or perverted nutrition (causing a deposit of fat in the 

organ) ; or hereditary predisposition. 

Exciting Causes. 

Bright's disease. 
Chronic alcoholismus. 
Gout. 
Phthisis. 

Cancer. ' . 

Calcification of the coronary vessels. 

Pericardial thickenings — causing external compression. 

Poisoning by phosphorus, phosphoric acid, chloroform, etc. 

General obesity. 

SYMPTOMS. 
Rational. 

The same as those of defective heart-power. 
Complete exhaustion after exercise. 
Skin — pale, sallow, and livid. 
Arcus senilis. 
Enlarged liver. 
Muscular flabbiness. 

Respiration — feeble and irregular, often sighing in character. 
Disturbed vision— from anaemia of the brain. 
Irritable temper — from anaemia of the train. 
Dementia. 

Dyspnoea — from pulmonary hyperaemia. 
Giddiness — from anaemia or passive hyperaemia of the brain. 
Vertigo — from anaemia or passive hyperaemia of the brain. 
Syncope — from anaemia or passive hyperaemia of the brain. 
Feeble Pulse. 

Physical. 

Inspection. — Feeble, sighing, or progressive respiration. Apex-beat 

is indistinct and often invisible. 
Palpation. ^Tumbling, rolling motion of " the heart (if hyper- 

trophied). 



CARDIAC THROMBOSIS 



Percussion. — Increased area of dullness (which is both superficial 
and deep), if hypertrophied — otherwise normal limits. 

Auscultation. — First sound is feeble or absent. Second sound is 
feeble but distinct. 

DIFFERENTIAL DIAGNOSIS. 
Between cardiac dilatation, and simple fatty heart. 

PROGNOSIS. 

There is always a fatal termination. This may occur from sjix- 
cope, rupture of the heart, cerebral anaemia, or general dropsy. 

TREATMENT. 

Iron, oleum morrhuce, good nutritious diet, fresh air, light ex- 
ercise, and the avoidance of all stimulants is all that can be sug- 
gested for the treatment of this disease, as the great and only 
object, to be obtained, is to improve, or increase the tissue-making 
power of the blood. 

CARDIAC THROMBOSIS. 
MORBID ANATOMY. 
Heart-clots may have existed for years, or only a short time 
previous to death; and vary in size from that of a pin-point to 
that of a walnut. They may be flat or round in shape. When 
small they are called vegetations, and when large, thrombi. They 
may be found in either of the cavities, or on the valves. 

ETIOLOGY. 

First — you may have obstruction to the flow of blood, which 
may be due to valvular lesions, dilatation, or feeble contractile 
power of the heart. 

Secondly — you may have abnormal changes in the composition 
of the blood. 

Thirdly — you may have endocarditis (causing a roughening of 
the endocardial membrane and subsequent formation of thrombi). 



144 



DISEASES OF THE CIRCULATORY SYSTEM. 



SY]MPTOMS. 
Rational. 

In grave cases. 

Heart— the action is frequent and irregular. 
Pulse — weak, small, and irregular. 
Syncope. 

Distended jugulars. 
• Restlessness and jactitation (with partial or complete pul- 
monic obstruction). 
Delirium. 
Convulsions. 
Coma. 

Physical. 

Inspection and Palpation. — Irregular cardiac impulse; dullness 
to the right of the sternum. 

Auscultation. — Marked irregularity of the hearfs action. Mur- 
murs, indicative of either tricuspid or pulmonic obstruction, 
heard with greatest intensity at the xiphoid cartilage, and 
conveyed to the left of the sternum. 

DIFFERENTIAL DIAGNOSIS. 
From lesions of the valves, or rupture of the chordae tendineae. 

PROGNOSIS. 

Is unfavorable. 

TREATMENT. 

Carbonate of potash, or sesqui-carbonate of ammonia; orammon. 
carb. gr. xxx. every two hours, and absolute quietude. 

NERVOUS CARDIAC PALPITATIONS". 
DEFINITION. 

Is a neurosis of the heart, but is not, as a rule, dependent upon 
heart-changes. 

ETIOLOGY. 

Violent physical exercise. Indulgence in alcohol. 



ANGINA PECTORIS. 



145 



Too rapid growth in youngs people, producing a narrrowing of 
the chest. 

Debility, anaemia, excessive sexual intercourse, typhoid fever. 
It may be induced by late hours, strong tea, coffee, tobacco, 
shock, fright, deranged digestion, flatulence, dyspepsia, gout, etc. 

SYMPTOMS. 

Heart — the action is irregular and often intermittent. 

Palpitation — slight, quick, prolonged, or heaving pulsation. 

Sense of uneasiness — in the precordial region. 

Sense of constriction, vreight, or pain in the region of the heart. 

Sinking and fluttering sensation in the epigastrium. 

Dyspnoea. 

Vertigo. 

Headache. 

Tinnitus aurium. 

PROGNOSIS. 

Is good, if no organic disease exist. 

TREATMENT. 

Remove the cause; and assure the patient that there is no dan- 
ger, provided organic disease be absent. 

■» 

AISTGINA PECTORIS. 
DEFINITION. 

Is a neurosis, dependent upon heart-changes (principally organic 
changes), causing defective heart-power. 

MORBID ANATOMY. 

It is associated with all the forms of cardiac or aortic disease, 
but especially with obstruction to the coronary circulation, and 
fatty degeneration of the muscular-tissue of the heart. It is 
claimed that there must be some nervous element present, having 
its seat in the pneumogastric nerve or cardiac Dlexus, causing 
cardiac spasm. 



146 



DISEASES OF THE CIRCULATORY SYSTEM. 



ETIOLOGY. 
Predisposing Causes. 
Obstruction to the coronary circulation from aortic regurgitation, 

or atheroma, or embolism of the coronary arteries. 
Fatty degeneration with suddenly disturbed heart's action. 
Exciting Causes. 

Mental emotion. 

Prolonged physical exertion. 

Errors of diet. 

Anything that disturbs the heart's action. 

SYMPTOMS. 
Rational. 

Pain — intense, agonizing, stabbing, lancinating, shooting through 
the back and along the left arm. This is a reflex act of the 
pneumogastric and phrenic or cardiac nerves to the cervical 
ganglia, and conveyed ofiward to the brachial plexus. 

Sense of suifocation. 

Countenance — pale and anxious. 

Pace — livid, and covered with perspiration. 

Pulse — faltering and almost imperceptible. 

Patient is usually unable to move (on account of the severity of 

the pain), or even lie down. 
No palpitation of the heart is usually present. 
Dyspnoea — very extreme and agonizing. 
Sense of approaching death. 
Syncope and death — sometimes. 

Physical. 

Inspection. — Respiration short and hurried. 

Auscultation. — A heart murmur (if the attack be due to a valvu- 
lar lesion). 

DIFFERENTIAL DIAGNOSIS. 

From spasmodic asthma; hysteria; intercostal neuralgia; my- 
algia; first stage of pleurisy. 

In spasmodic asthma — the physical examination will determine 
the absence of heart-lesions. 



BASEDOW'S DISEASE. 



147 



In hysteria— the intermittent and irregular pulse of angina 
pectoris will be wanting; and the pain and rational symptoms 
will be less severe. 

In intercostal neuralgia— there will be the duration of the 
attack; the direction of the pain, and the absence of cardiac dis- 
turbance, to assist in the diagnosis. 

In myalgia — the condition of the circulation, locality of the 
pain, and the physical signs, are sufficient to exclude angina 
pectoris. 

PROGNOSIS. 

Is unfavorable. The patient may recover from first attacks. 
TREATMENT. 

Remove the exciting cause and alleviate the symptoms. The 
patient must be kept quiet and plenty of digitalis administered; 
also iron, strychnia, or arsenic daily in small doses. 

BASEDOW'S DISEASE. 
SYNONYM. 
Exophthalmic goitre— Grave's disease. 

DEFINITION. 

Is a disease characterized by a subjective sense of palpitation, 
accompanied by acceleration of the heart's action; pulsation of 
the veins in the neck and head; swelling of the thyroid gland; 
4,nd protrusion of the eyes from their orbits. 

ETIOLOGY. 

The protrusion of the eye from the orbit is caused by a semi- 
paralysis of the vaso-motor nerves, thus affecting the blood- 
vessels. The muscles of the heart may be affected from the same 
cause (occasioning many of the other above-named symptoms). 
The eyes may also be caused to protrude by intra-orbital fat; by ab- 
scess, or tumor in the areolar texture of the orbit; and by exostosis 
of the parietes of the orbit. It may follow menstrual disorders, 
or lack of red blood-corpuscles in the blood. It is more common 
among women than men. 



148 



DISEASES OF THE CIRCULATORY SYSTEM. 



SYMPTOMS. 



Palpitation of the heart — with remarkable frequency of pulse 

(120 to 140). 
Swelling of the thyroid gland. 
Protrusion of the eyes. 

Eyelids— incapable of covering the eyeballs (which may cause in- 
filtration or abscess of the cornea, or total destruction of the 
eye). 

Loss of sight (sometimes) from abscess and perforation of the 
cornea. 

Spasmodic contraction of the levator palpebrae superioris. 
Peculiar rustling sound in thyroid gland (on auscultation). 
Blowing sound at the heart (blood-murmurs). 
Oppression in the throat. 
Dizziness. 



May occur with cerebral symptoms, or from an intercurrent 
disease. 



Strengthening diet; iron; secale eornutum (ergot); constant and 
induced current to cervical portion of the sympathetic. 



Headache. 

Cyanosis. 

Dropsy. 

Extreme dyspnoea. 



In severe cases during the full development 
of the disease. 



DEATH. 



TREATMENT. 



DISEASES OF THE DIGESTIVE 
TEAOT, 



DISEASES OF THE DIGESTIVE TRACT. 



Under this heading I have included: 

1. Diseases of the Mouth. 

2. Diseases of the Pharynx. 

3. Diseases of the (Esophagus. 

4. Diseases of the Stomach. 

5. Diseases of the Intestines. 

6. Diseases of the Liver. 

The liver, being classed as one of the accessory organs of diges- 
tion, can properly be included under this head. 



DISEASES OF THE MOUTH. 

CATARRH OF THE MOUTH. 
DEFINITION. 

Catarrh is a term applied to all simple inflammations of the 
mucous membranes of the body; hence to the mucous membrane 
of the mouth. 

MORBID ANATOMY. 

The mucous membrane is, at first, dark-red; subsequently be- 
coming dry, and finally a copious, cloudy secretion takes place. 
Early in the affection, there is swelling of the mucous membrane, 
increased secretions, and an excessive formation of young cells. 
There may be impressions of the teeth perceived upon the sides 
of the tongue. A mucus, which is turbid and foul, covers the 
cheeks, gums, and tongue (called " coated tongue"). 

On microscopical examination, the coating of the tongue con-, 
sists of epithelial cells, containing fat-globules and brown granules. 



153 



DISEASES OF THE DIGESTIVE TRACT. 



SYMPTOMS. 
Rational. 
Burning and tension in the mouth. 
Slimy, clammy taste (bilious). 

Foul taste or smell (often perceived by the olfactory nerve of the 
patient). 

Craving for sour, salty, and highly-seasoned food. 
In children — it may accompany teething; convulsions (reflex 
symptom) may also exist. 

PROGNOSIS. 

Is favorable, except when the attacks occur during dentition. 

Unless the affection become chronic, it is usually curable in a 
short time, provided the patient follow the directions that are 
given. 

TREATMENT. 

Remove all irritation (as sharp edges of teeth, etc.). Forbid 
smoking strong cigars. When smoking is a confirmed habit, the 
cigars should be weak ones and a holder used. If it occur from 
mercurials, discontinue them. For obstinate foulness of the 
mouth, the patient should chew slowly smaU pieces of rhubarb 
before going to bed. 

APHTHA. 
SYNONYM. 

Croupous stomatitis " — a frequent disease of infants. 

MORBID ANATOMY. 
It occurs on the anterior half of the tongue and inner surface 
of the lips, cheek, and hard palate, in gray or yello'^'ish-white 
deposits with a red border, which excoriates the parts, but does 
not cause ulceration. On the free surface of the mucous mem- 
brane under the epithelium, are small solid white spots with a red 
border (consisting of exudations). 



CANCRUM ORIS. 



153 



ETIOLOGY. 

It occurs chiefly in weakly and badly-nourished children, or, 
may be due to dentition. It may also occur as an epidemic. 

SYMPTOMS. 

Fever. 

Restlessness. 
Loss of appetite. 

Pain— which is increased when the child is being suckled. 
Fetor of the mouth — from decomposition of the epithelium and 
the exudation which is thrown off. 

TREATMENT. 

Chlorate of potash, gr. iv.-vi. should be given, or the parts 
painted with dilute muriatic acid, or a solution of nitrate of silver 
(gr. i. to I ss. of water). 



CANCEUM ORIS. 
SYNONYM. 
*' Diphtheritic stomatitis." 

DEFINITION. 

Is a fibrinous exudation, accompanied by sloughing of the 
mucous membrane, from compression of the vessels (due to exu- 
dation). 

MORBID ANATOMY. 

In mild cases — it shows itself in the form of white spots along the 
lateral border of the tongue and on the parts of the cheek and 
lips which lie against the teeth. These spots after a time fall off 
and leave an ulcer. 

In severe cases— when the whole mucous membrane is destroyed, 
a large portion of the mouth is converted into a soft discolored 
slough which may separate and leave an irregular border and an 
uneven base. This may be replaced by cicatricial tissue. Ad- 



154 



DISEASES OF THE DIGESTIVE TRACT. 



hesions and false anchylosis may occur, and sometimes caries and 
necrosis of the maxillary bones may ensue. 

ETIOLOGY. 

From excessive use of mercurials. It occurs as an epidemic in 
Foundling Hospitals, Orphan Asylums, Barracks, Armies in the 
field, etc. 

SYMPTOMS. 

Severe pain — especially when there are ulcers formed. 
Increased salivary secretion. 

Insomnia— due to the secretions going into the 'larynx and pro- 
ducing fits of coughing, or suffocation. 
The edges of the teeth are coated with a foul deposit. 
Fetid odor to the breath. 

Gums — dark, red, and swoUen from excessive hypersemia. 

Teeth— loosened and bleed easily. 

Diphtheritic pulpy deposit on the gums. 

Lymphatic glands are swollen and painful. 

(Edema of the lips and cheeks. 

Saliva— bloody and discolored. 

PROGNOSIS. 

When properly treated, it runs a favorable course and heals. 
If it be neglected, it may last for months. Is fatal only when 
complications occur. 

TREATMENT. 

The cure is slow. It will take eight to nine days to get the pa- 
tient even in a comfortable state. "Wash the mouth out with cold 
water, or water and red wine, or chlorate of potash 3 j- 3 j-ij dis- 
solved in % vi. water. Paint the mouth with a solution of nitrate 
of silver (gr. i.- 1 ss.), or touch the ulcers with solid nitrate of sil- 
ver. This last treatment is exceedingly painful. 

THRUSH. 
SYNONYMS. 
" Soor," " muguet/' or " sprue." 



NOMA. 



155 



MORBID ANATOMY. 
There is a whitish, delicate, frosty coating on the inner surface 
of the lips, tongue, and roof of the mouth, advancing to the 
larynx and oesophagus. It may extend, downward, along the 
digestive tract. 

ETIOLOGY. 

From fungus growing on the mucous membrane of the mouth ; 
diminished secretions of the mouth ; and the neglect of cleansing 
the mouth. It occurs most often in infants; and in adults, gener- 
ally before death. It is always a bad symptom in adults if follow- 
ing some serious disease. 

SYMPTOMS. 

Painful burning in the mouth. 
{In a child.) 

Diarrhoea — with pain in the abdomen. 

Stools — fluid, green, and acid. 

Anus — red, and excoriated. 

TREATMENT. 

Cleanliness of the mouth; which must be washed out with wine 
and water after feeding. Borax is often used as a local applica- 
tion. 

^s^OMA. 

SYNONYMS. 
"Water-canker," or gangrenous sore mouth." 

MORBID ANATOMY. 
It commences on the inside of the cheeks, over a hard spot 
which has previously developed; the mucous membrane is red, 
and discolored, and vesicles filled with serum form on this spot. 
The part becomes black, softens, aad disintegrates; the gums are 
destroyed, and also the lips and base and edges of the tongue on 
the affected side. The teeth become looce and fall out. ' The 
whole of one side of the face may have become a black slough (in 



156 



DISEASES OF THE DIGESTIVE TRACT. 



about five or six days). On post-mortem examination, the blood- 
vessels are filled with a fibrinous coagula. 

SYMPTOMS. 

CEdema— of the affected cheek and lips, with a hard, round nu- 
cleus at the seat of the disease. 
Saliva — is bloody and black. 
Pulse — small and frequent. 
Delirium — at night. 
Thirst — unquenchable. 
Diarrhoea — is usually present. 

PROGNOSIS. 

Recovery is rare; and, when it does occur tHere is a large cica- 
trix left, often causing fearful disfigurement. 

TREATMENT. 

Give the patient plenty of fresh air, good nourishment, wine, 
etc., and treat the gangrene locally by actual cautery. 



SYPHILITIC AFFECTIONS OF THE MOUTH. 
VARIETIES. 

Primary — often due to nursing of an infant by a syphilitic nurse; 

the affection may appear during later years in the form of 

ulcers and condylomata. 
Secondary — occurs in the early stages, and both forms (ulcers and 

condylomata) often appear together. 
Tertiary — occurs in the later periods, in the form of gummy 

tumors, or nodular syphilomata. Caries of the hard palate 

may also be developed. 

MORBID ANATOMY. 
The primary and secondary ulcers and condj^lomata spring from 
circumscribed indurations, or syphilitic papules of the mucous 
membrane, giving a white appearance to the affected part. They 



ULCERS OF THE MOUTH. 



157 



occur especially at the corners of the mouth, and have the appear- 
ance as if the corners were torn. Condylomata usually form on 
the lateral edges or dorsum of the tongue. Gummy tumors fre- 
quently appear on the anterior third of the tongue which soon 
soften and rupture, leaving deep ulcers. 

SYMPTOMS. 
Pain — on chewing, and sometimes of mouth. 
Mucous patches — these often disappear and reappear on some 
other spot. 

Tongue— is unwleldly, and often rigid if extensively diseased. 
TREATMENT. 

Mercury and iodide of potash. Calomel as a dusting powder to 
the condylomata. Fumigation of the mouth with the vapor of 
calomel or the black oxide of mercury. 

ULCERS OF THE MOUTH. 
MORBID ANATOMY. 
There may be small vesicles at the end of the tongue, and ulcers 
showing catarrhal inflammation. Variolous ulcers may appear on 
the roof of the mouth, and herpetic ulcers may occur on the in- 
side of the cheek; the bases of these ulcers have a yellow or larda- 
ceous appearance, and their edges are usually elevated, hard, and 
red. Syphilitic ulcers (mucous patches) are most frequent in the 
mouth or fauces. There may be small excoriations, as if the 
mouth had been burnt, from smoking, or drinking something 
hot. 

ETIOLOGY. 

Follicular ulcers from stoppage, swelling, and ulceration of- 
mucous glands, may occur at the menstrual epoch, or during preg- 
nancy, or lactation. The other types depend upon special blood 
conditions. 

SYMPTOMS. 

Great pain — when the ulcers are diffused and not syphilitic. 



158 



DISEASES OF THE DIGESTIVE TRACT. 



Disturbed digestion — (may occur) if the ulcers be follicular in 
character. 

PROGNOSIS. 

Is rarely dangerous, although the ulcers may last for weeks. If 
syphilitic, they recur and tend to progress forward toward the 
lips. 

TREATMENT. 

Smoking, drinking hot beverages, eating highly-seasoned food, 
etc., must be avoided. The ulcers should be touched ^vith solid 
idtrate of silver. A weak solution of corrosive sublimate will 
often be found very beneficial. 

SALIVATIOK. 
SYNONYM. 

''PtyaUsm." 

DEFINITION. 

Is a disease where the increased secretion of the salivary glands 
ceases to pass into the stomach with the ingesta; but flows con- 
stantly out of the mouth, if the case be severe. 

MORBID ANATOMY. 
The saliva contains yoimg and old epithelial cells. The saliva 
is alkaline, and contains fat and ptyaline, and sometimes sulpho- 
cyanide of potassium and mucus corpuscles. The teeth become 
loose, if due to mercurj^; the tongue is oftentimes so swollen as 
to protrude; while the peculiar foetor of mercurial is very 
marked. 

ETIOLOGY. 

Simple salivation may occur from irritation of the mucous 
membrane of the mouth, or pharynx; from introduction of irri- 
tating substances into the mout^i; from irritation of the lingual 
branch of the trifacial, or glosso-pharyngeal nerve: from neural- 
gia of the trifacial nerve; from irritation affecting tlie gastric, or 
intestinal mucous membrane, or uterus, or other organs; from 



PAROTITIS 



159 



mental influences (disgust and desire) ; from pregnancy ; from 
disease, as typhus or intermittent fever, etc. The most marked 
type of salivation follows; mercurial poisoning. 

SYMPTOMS. 
Constant spitting — (at the onset). 
Emaciation. 

Constant flow of saliva — sometimes reaching from six to eight 

pounds in twenty-four hours. 
If due to mercurial poisoning— a swollen and protruding tongue; 

loosened teeth; foetid breath. 

TREATMENT. 

If it occur from misuse of mercury, give slight laxatives and 
purgatives, and an astringent gargle. 

If from affections of the stomach, etc., then treat the disease. 

General baths, blisters, mustard to the throat and nape of the 
neck, mouth washes of alum, sulphate of zinc, sage, or oak-hark 
have been recommended, as also opium, to diminish the excita- 
bility of the nerves. 

PAEOTITIS. 
SYNONYM. 

" Mumps." 

VARIETIES. 

Idiopathic; symptomatic; polymorpha or "mumps;" or metas- 
tatic. 

MORBID ANATOMY. 

Idiopathic parotitis— Is believed to be due solely to a serous 
exudation from a catarrh of the gland-duct, affecting the inter- 
stitial substance and connective-tissue about the gland. 

Symptomatic parotitis — Begins with hyperaemia, causing infil- 
tration and swelling of the interstitial substance of the gland. 
The gland becomes tough and filled with a whiti.sh or yellowish 
substance, which soon turns purulent, giving the gland the 



160 



DISEASES OF THE DIGESTIVE TRACT. 



appearance of lobules filled with pus. Destruction of the tunica 
propria takes place, and suppuration ^f the interstitial-tissue 
occurs, which extends rapidly, and often results in a large parotid 
abscess. Sometimes there is destruction of the gland-tissue, and 
gangrene attacking the neighboring connective-tissue, and mus- 
cles of mastication, and also the periosteum of the maxillary, 
temporal, and sphenoid bones, and sometimes the bones them- 
selves. The inflammation, in severe cases, often extends to the 
brain, or internal and middle ear; this may take place along the 
blood-vessels and nerve-sheaths, as well as the bones themselves. 
It sometimes induces phlebitis and thrombus of the neighboring 
veins (especially of the anterior and posterior facial and external 
jugular) and disintegration of these thrombi, thus producing em- 
bolism and septicaemia. 

SYMPTOMS. 

Idiopathic form. 

General febrile symptoms for two days. 

Swelling— near the lobe of the ear, extending to the cheek 
and neck; and then to the other side of the face. After 
five or six days, the fever ceases and all the symptoms 
may disappear in ten days. The tumor may become very 
painful, hard, and dark-red; abscesses may form, which 
open outwardly, or into the external auditory meatus 

Testicles —may be affected (by metastasis). 

Pain — in the sacral and inguinal region may exist and an ex- 
acerbation of the fever may occur. 

CEdema— of the scrotum (in men), and vulva and breast (in 
women), and pain in the ovaries. 

Meningitis — may sometimes occur and prove f ata- 
Symptomatic form. 

Occurs in various diseases, and is accompanied by a chill, or 
exacerbation of fever. It usually affects only one side. 

When suppuration takes place, the swelling becomes uneven, 
nodulated, and red. Fluctuates at points; may open 
outwardly into the meatus auditorius externus, but 
generally into the mouth or pharynx; or it may burrow 



GLOSSITIS. 



161 



down into the oesophagus, trachea, or chest. While mor- 
tifying, the skin becomes dark-blue and discolored, 
doughy in feel, and depressed. On opening tumor there is 
evacuated a discolored pus with shreds of tissue. 

TREATMENT. 

In the idiopathic form. — The bowels and digestion should be 
regulated, and the patient protected from all injurious influences. 
The part should be covered with wadding, etc. Much meat 
should not be allowed, only food which is easily digested. If the 
tumor be hard and swollen, leeches should be applied; if fluctu- 
ant, it should be opened and poultices applied. 

In the symptomatic form. — If the swelling be red or painful on 
pressure, apply ice and cold water; if fluctuant, open and apply 
poultices. 

GLOSSITIS. 
DEFINITION. 
Is a parenchymatous inflammation of the tongue. 

VARIETIES. 

Acute — Chronic — Dissecting — and Superficial or " psoriasis." 
MORBID ANATOMY. 

In the acute form. — The whole tongue becomes very large, 
darkened in color, smooth, or fissured, and covered with tough 
bloody exudations. Abscesses may form and leave a scar. 

In the chronic form. — Only a part of the tongue may be 
affected, especially the edges, where circumscribed spots may 
project. 

In the dissecting form. — The tongue is divided into lobules by 
furrows, causing ulceration from lodgment of food, etc. 

In the superficial form. — The tongue looks glossy and smooth 
as though it were varnished or scalded. 

SYMPTOMS. 

Tongue— is enlarged and projects often one inch beyond the teeth, 
and is white or dirty-brown on its upper surface, or dark-red 



163 



DISEASES OF THE DIGESTIVE TRACT. 



on the under surface; ulcers may occur, or there may oe im- 
paired movements and the speech unintelligible. 

Flow of saliva— is constant. 

Glands of the neck are enlarged. 

Face may be blue and swollen from obstruction to the jugulars. 
Impaired respiration — from stoppage of entrance of air into the 

larynx, due to swelling of the tongue backward, may occur in 

severe cases. 
In the acute form. 

High fever. 

Full pulse. 

Anxiety. 

Restlessness. 

Asphyxia. 
hi the chronic form. 

Circumscribed dull pain, which may last for years. 

TREATMENT. 

In the acute form. — Scarify deeply. Then put ice in the mouth 
and give soothing washes. If suffocation threaten, then perform 
tracheotomy. 

7n ^Tie c/iromc /orm.— Remove all obstacles to recover5^ Should 
this fail, an operation must be resorted to. 

In the dissecting form.— TrediX, the ulcer with nitrate of silver 
in substance or solution. 

In the superficial form.—Tio not give mercury, as it increases 
the pain, but rinse the mouth out with a dilute solution of car- 
bolic acid, and touch the fissures with pure carbolic acid. 



TONSILLITIS. 
SYNONYM. 

Quinsy." 

DEFINITION. 

Is an inflammation of the interstitial-tissues of the tonsils, and 
proliferation of the connective-tissue, which may be acute or 
chronic in character. 



TO^'SILLITIS. 



163 



MORBID ANATOMY. 
The tonsils sometimes swell to the size of a walnut, the surface 
is nodulated, dark, and red, and covered with a glutinous exuda- 
tion, or croupous deposits. Suppuration may occur. 

SYMPTOMS. 

Chill and high fever (especially if pus be developing). 
Temperature— 104°, and sometimes even higher. 
Pulse — frequent and full. 
Throat — tense and sore. 

Pain — piercing, and shooting toward the ear. 
Difficulty and pain in opening the mouth, or in chewing. 
Mouth — cannot be opened widely. 
Eespiration — is affected. 

Uvula— may be deflected to one side, and tonsils enlarged. 
There may be severe headache. 
Insomnia may be present in severe cases. 
Delirium may be present in severe cases. 

Symptoms of asphyxia — may occur, if extensive suppuration 
occur. 

TREATMENT. 

Powdered alum (two or three times daily) should be applied to 
the affected part. Rinse out the mouth with a solution of alum, 
3 iij.- 1 ss. to § vi. of barley-water. Apply nitrate of silver to the 
affected part. Cold applications may be used — as ice, cold water, 
or cold compresses, changing them frequently. If fluctuation 
occur, a warm poultice should be applied, and the mouth washed 
out with chamomile tea. Open the abscess early with the finger- 
nail, or lancet. Be careful in using the knife, as the carotid 
artery may be wounded. 

If there be cerebral troubles, give laxatives. If it become 
chronic, paint the parts with a solution of alum, nitrate of 
silver, dilute tincture of iodine; or cold compresses may be 
applied. 



164 



DISEASES OF THE DIGESTIVE TRACT. 



ANGINA LUDOVIOL 
DEFINITION. 

Is a phlegmonous inflammation of the floor of the mouth, and 
intermuscular and subcutaneous connective-tissue of the sub- 
maxillary region, leading to gangrene and sloughing, or ending 
in abscess, or resolution. It is often termed "Gangrenous in- 
flammation of the neck." 

ETIOLOGY. 

From periostitis of the lower jaw, or metastatic parotitis, oc- 
curring in typhus and other infectious diseases, starting from the 
submaxillary gland. 

SYMPTOMS. 

Swelling in the floor of the mouth (upward and downward). 

Loss of motion of the tongue. 

Inability to open the mouth (abscesses may form). 

Fever and general constitutional derangement. 

Death — from oedema glottidis, suffocation, or septicaemia, etc. 

TREATMENT. 

Apply a large number of leeches near the seat of the tumor. 
When the tumor is fluctuating in character, the contents should 
be evacuated as soon as practicable. If suffocation be appre- 
hended, then scarify. Tracheotomy may be resorted to in dan- 
gerous cases. If a hard tumor remain for a long time, then apply 
blisters freely and repeatedly. 

DISEASES OF THE PHARYNX. 

PHAEYNGEAL CROUP. 
DEFINITION. 

Is a fibrinous inflammation of the pharyngeal mucous mem- 
brane. 



RETRO-PHARYNGEAL ABSCESS. 165 

MORBID ANATOMY. 
White, or grayish-white membranous masses are seen on the 
reddened mucous membrane of the soft palate, tonsils, and 
phaiynx, like small irregular round islands. The membrane 
often adheres so firmly that, on detaching it, a bloody superficial 
loss of substance remains. This indicates a change from the 
croupous to the diphtheritic form. 

SYMPTOMS. 

Dryness of the throat, local inflammation, and gray patches — 

which may be mistaken for ulcers. 
Great pain — in the arches of the palate, chiefly on attempts to 

swallow. 
Uvula — elongated. 
Nasal tone of voice. 
Coated tongue, etc. 

Pulse and temperature — may be elevated, if the case be severe. 
TREATMENT. 

If the attack be mild, it should be left alone; but if of a severe 
type, apply moist compresses well wrung out, and covered with 
dry cloth, or warm poultices, to the throat. Wash out the mouth 
with water, or a solution of alum, sulphate of zinc, acetate of 
lead, etc. Cover the inflamed parts with powdered alum, or paint 
them with a solution of nitrate of silver ( 3 i. to § i. water). If 
it accompany croupous laryngitis, remove the membrane, and 
cauterize it with nitrate of silver. 

EETRO-PHARYNGEAL ABSCESS. 
DEFINITION. 

Is an abscess between the textures of the pharynx (its posterior 
wall) and the cervical vertebrae. 

MORBID ANATOMY. 
The posterior wall of the pharynx is pressed forward by pus, 



166 



DISEASES OF THE DIGESTIVE TRACT. 



causing contraction, or closure of the pharynx. It may perforate 
the pharynx, or even extend down to the pleura. 

SYMPTOMS. 

Difficult swallowing. 
Restlessness. 

Croupy coughing and choking. 
Continual dyspnoea. 
Large fluctuating tumor. 

CAUSES OF DEATH. 
Complete closure of the glottis. — CEdema glottidis.— Opening of . 
the abscess during sleep. — Entrance of its contents into the 
larynx. — Pleuritis. — Pneumonia. — Pericarditis. 

TREATMENT. 
Open the abscess at once with the finger-nail, or lancet. 



DISEASES OF THE (ESOPHAGUS. 



STEIOTURE OF THE CESOPHAGUS. 
It occurs most frequently in the lower third, but it may affect 
any part of the tract. The walls are hypertrophied and the canal 
dilated above the stricture; while the walls are thinned and the 
canal collapsed below the stricture. 

MORBID ANATOMY. 
It depends on cicatricial contractions and considerable loss of 
substance (as in corrosions or ulcerations) or, on hypertrophy of 
the muscular, or intermuscular connective-tissue; from chronic 
catarrh (which on section gives a fan-like appearance) or, from 
hypertrophy of the submucous-tissue. 

ETIOLOGY. 

From compression due to swelling of the thyroid body; swell, 
ing of the lymphatics; dislocation of tlie lupoid bone; exostosis of 



DILATATION OF THE CESOPHAGUfe. 



167 



the vertebrae; abscess; tumor; aneurism; carcinoma of the lungs; 
dilatation of the right subclavian artery; protrusion of new 
growths into its canal (carcinomatous); structural changes in its 
walls; previous inflammation and ulceration. 

SYMPTOMS. 

Difficulty of swallowing. 
Pain about the manubrium and back. 
Regurgitation of food. 
Constipation from starvation. 

TREATMENT. 
Dilatation— by mechanical means. 



DILATATION OF THE OESOPHAGUS. 
MORBID ANATOMY. 
In total dilatation. — The canal may be the size of a man's arm, 
with hypertrophied or thinned walls. 

In partial dilatation. — That portion of the canal above the 
constriction is usually the largest. 

The diverticuli usually form near the bifurcation of the trachea, 
or where the pharynx terminates, and the oesophagus begins. 

ETIOLOGY. 

It may be partial when limited to a short distance, or total 
when the entire organ is affected. When partial, only one wall 
may be affected. Localized enlargements may occur, developing 
into large sacs, communicating with the oesophagus, and termed 
diverticuli; these (diverticuli) are formed by foreign bodies that 
have stuck into the walls, and have been driven further in by the 
food as it passes down, or, by the shrinkage of the bronchial 
glands which were adherent, when swollen, to the mucous mem- 
brane, and, on contracting, draw the mucous membrane after 
them. Total dilatation is due to a chronic catarrh, which in- 
duces muscular paralysis. 



168 DISEASES OF THE DIGESTIVE TRACT. 

SYMPTOMS. 

In partial dilatation. 

Retention of food — then regurgitation (the food being mixed 

with mucus). The food may sometimes be decomposed. 
Diverticuli — when present may be felt in the neck like a soft 
tumor. 

Dyspnoea — from the diverticuli causing compression of sur- 
rounding structures (as the pneumogastric, laryngeal, or 
phrenic nerves). 

Death — from starvation. 

TREATMENT. 

Is of no use. The stomach tube may be resorted to, provided 
it can be passed through the diverticuli. In this event, there 
may be some slight hope of recovery. 

PERFOEATION AND RUPTURE OF THE 
(ESOPHAGUS. 
ETIOLOGY. 
May occur from within outward or the reverse. 
From within outtvard. 

From breaking down of a cancer; ulcer (caused by splinters 
of bone (rare)); deep sloughs (excited by corrosion). 
From without inward. 

From aneurism of the aortd,; breaking down of a tuberculous 
gland at the bifurcation of the trachea; abscesses in the 
interior surface of the spine; caries of the vertebrae; 
tuberculous cavities in the lungs. 

SYMPTOMS. 

Pain — severe and sudden, in the breast. 

Chill. 

Paleness. 

Coldness of the extremities. 
Faintings and attacks of suffocation. 



NERVOUS AFFECTIONS OF THE CESOPHAGUS. 



169 



Profuse vomiting of blood (in case of aneurism), or of pus (in 
case of abscess). 



NERVOUS AFFECTIONS OF THE (ESOPHAOUS. 



Globus Hystericus. — Hypersesthesia, or increased excitability of 
the sensory nerves, and feeling as if the oesophagus were 
ligated, and a" supposed inability to swallow. 

Hyperkinesis or Dysphagia Spastica. — Is an increased excitability 
of the motor nerves. The spasm is reflex and forms a symp- 
tom of brain-disease, or of the upper part of the cord ; or, it 
may result from poisoning by narcotics or in alcoholism. It 
usually occurs during eating. 

Akinesis. — Is a diminished excitability of the motor nerves. It 
accompanies diseases of the brain and cervical portion of the 
cord. If complete paralysis exist, there is inability to swal- 
low; but if incomplete paralysis, large pieces of meat and 
food are able to be swallowed. 



For Globus hystericus or Hyperkinesis. 

Belladonna, valerian, asafcBtida, musk, etc. Also repeated and 
careful introduction of the bougie. 
For Akinesis. 

Probe, electricity, and strychnia (?). 



TREATMENT. 



None. 



TREATMENT. 



DISEASES OF THE 




ACUTE GASTRIC CATARRH. 



DEFINITION. 



Is an acute catarrhal inflammation of the mucous membrane 
of the stomach. 



170 



DISEASES OF THE DIGESTIVE TRACT. 



MORBID ANATOMY. 
The mucous membrane is reddened in spots, but the result is 
generally negative. Beaumont's observations on St. Martin 
showed the mucous membrane reddened and covered with tough 
mucus, with traces of blood; the mucous covering became subse- 
quently thickened, and the gastric juice suppressed. The walls 
of the stomach, on post-mortem, may show spots of softening, 
and the mucous lining may be eroded from fermentation. 

ETIOLOGY. 

It occurs in fevers, pneumonia, etc. (from neglect of simple 
dietetic rules, producing anorexia, and capricious appetite); in 
debilitated and badly nourished persons (producing diminution 
in the gastric juice from decreased amount of blood in the system 
and hydrsemia resulting in a diminution of albuminates, of which 
pepsin is made and which is the organic constituent of the gastric 
juice). From excess in drinking and error in diet in children; 
large quantities of easily digested food taken, and diminution of 
gastric juice causing decomposition of food; use of indigestible 
food (producing decomposition); substances that have commenced 
to decompose before entering the stomach; irritation of hot or 
cold articles, medicines, alcohol or spices; introduction of articles 
that weaken the gastric juice, or retard the movement of the 
stomach (producing abnormal decomposition of its contents), as 
misuse of alcohol, etc.; from narcotics (producing impaired 
movements of the stomach); catching cold; and infection. 

SYMPTOMS. 
General malaise and feeling of nausea. 
Dullness and fretfulness. 
Head — hot, and possible headache. 
Extremities — cold. 

Pressing pain in the forehead, extending to the occiput. 
Flashes before the eyes on stooping. 
Pain at the pit of the stomach. 
Distaste for food and great thirst. 

Belching of sulphuretted hydrogen and carbonic acid gas. 



CHRONIC GASTRIC CATARRH. 



171 



Sour fluid occasionally rises in the mouth. 
Tongue — coated. 
Taste — stale and slimy- 
Retching and vomiting. 
Severe diarrhoea. 

PROGNOSIS. 

Previously healthy persons rarely die. From repeated attacks, 
weakly and decrepit persons may die of gastric or catarrhal fever. 
In children, it may end fatally. 

TREATMENT. 

Watch the diet carefully. Milk should be the principal diet. 
If injurious food has been taken, give an emetic of ipecacuanha 
or tartrate of antimony. 

Should there be prominence of the epigastrium and eructation 
of gases, give ipec. 3i. and tart, antimony gr. i., but not where 
the fever is high and there are signs of typhus fever present. If 
colicky pains, escape of flatus, etc., exist, administer rhubarb or 
compound infusion of senna or magnesia usta ( § ss. to § viij. of 
, water) one tablespoonf ul every hour or two. If it should occur 
from excess of beer or wine, sodii bicarb, gr. v.-x. should be given. 
If the catarrh be slight and there be characteristic vomiting, give 
pulv. rhei co. ; if diarrhoea be more severe, tr. rhei aquosa, or small 
doses of calomel (gr. ^-\) should be given two or three times daily, 
or calomel, gr. iv.; pulv. jalapae, gr. ij.; sac. albi, 3 ss.; fiat pulv. 
_viij. Take one powder in water every two hours; or argent, 
nit.,gr. ^; aquae, § ij. M. Sig. 3 i. every hour. If the catarrli be 
slight and no vomiting exist, acidi tannici, 3ss. ; aquae, § iij. M, 
Sig. 3 i. every two hours, may be administered. 

CHEONIO GASTRIC CATARRH. 

MORBID ANATOMY. 
The mucous membrane is a reddish-brown, or slate color, from 
transformation of the heematin into pigment. There is a coarse 
anastamosis, or dilatation of the vessels. The mucous membrane 



172 



DISEASES OF THE DIGESTIVE TRACT. 



becomes hypertrophied and forms numerous folds. There are 
innumerable small prominences, separated by furrows, which ai'e 
most frequent in the pyloric end of the stomach. A grayish- 
white tough mucus covers, and clings to, the inner surface of the 
stomach; and, constriction of the pylorus takes place, through 
thickening of the walls of the stomach, from simple hypertrophy. 

ETIOLOGY. 

From continued and repeated attacks of the acute form; habit- 
ual misuse of spirituous liquors (especially); congestion of the 
gastric mucous membrane; obstructed circulation in the portal 
vein or liver. It accompanies phthisis and other chronic diseases: 
cancerous or other degenerations of the stomach; and may extend 
to the mouth and intestines. 

SYMPTOMS. 

Abnormal sense of pressure and fullness in the stomach (which is 

increased by eating). 
Prominence of the epigastrium— (from gas). 
Constant eructations — (from stricture of the pylorus). 
Vomiting (rare)— occurs in drunkards as " water-brash." 
Sensation of hunger is lost (in some cases). 
Wolfish appetite (in some cases). 
Mental depression. 

Change in the urine — (difficult to understand) becomes scanty. 
Death — may occur from marasmus (due to stricture of the pylorus 
or dropsy). 

PROGNOSIS. 

Is rarely fatal. 

TREATMENT. 

Never give emetics. Forbid all spirituous liquors. Patient 
should wear warm clothing, and take baths to excite the activity 
of the skin. Do not allow a vegetable diet, fat meats, or sauces. 
The diet should consist of lean meat which must be slowly and 
carefully masticated, and only small quantities to be taken at a 
time, or cold meat and a little white bread, or salt or smoked meat 
and sea-biscuits; milk, or butter-milk which is better (ad libitum). 



CARCINOMA OF THE STOMACH. 



173 



Soda or Karlsbad water may be prescribed, or bismuthi nit. gr. x. 
Argenti nit. gr. i.-ij. before breakfast (while fasting). 

If there be atony of the gastric mucous membrane, give iron and 
mild stimulants, alsoipec. gr. ss.-ij.; pulv. rhei gr. iij.-iv. in pills 
before meals. If constipation be present, give an enema, or some 
laxative such as aloes, ext. colocynth co. or comp. ext. rhei. 
Aloes and colocynth are the best. 

Never administer senna or oleum ricini. 

OAECIlSrOMA OF THE STOMACH. 
MORBID ANATOMY. 

The cancer may vary in size from about the size of a pigeon's 
egg to that of a man's fist; it attacks the pyloric portion, princi- 
pally, and spreads transversely, causing an annular stricture. The 
most frequent form of cancers are the scirrhus, medullary, 
alveolar or colloid (rarest). The colloid lasts a long time; induces 
ascites; and after tapping, may be felt as nodular masses appear- 
ing on the omentum. 

Scirrhus — begins in the sub-mucous tissue, forming irregular 
nodules; it has the appearance of a dull, whitish, dense mass of 
cartilaginous hardness, which softens to a black pulp and then 
sloughs. 

Medullary — looks like brain substance; on section giving off a 
"cancer juice." It spreads more rapidly than the other forms 
(often reaching the size of the hand). 

Alveolar or Colloid — occurs more frequently as diffused degener- 
ation. Commences in the submucous tissue and contains a gela- 
tinous fluid. It often extends to other organs, especially the 
lymphatics, pancreas, liver, transverse colon, or omentum. It 
induces degeneration of the peritoneum and consequent ascites. 
Prior to adhesion to other organs, the contents of the stomach 
may escape into the abdomen, if the ulceration penetrate its 
coats. 

ETIOLOGY. 

Is obscure. It is sometimes primary, but usually secondary, to 
cancerous degeneration of other organs. It may be hereditary. 



174 



DISEASES OF THE DIGESTIVE TRACT. 



and occurs more in men, especially between forty and sixty years 
of age. 

SYMPTOMS. 

Emaciation. 

Feeling of pressure in the epigastrium. 

Patient becomes apathetic. 

Loss of appetite, and constipation 

Vomiting. 

Tumor in the epigastrium— (sometimes absent to the touch) — most 
of those that can be felt are at the pyloric end of the stomach, 
and hence the tumor is generally on the left of the median 
line of the body, or near the umbilicus, from sinking of the 
pyloric end; it is uneven, nodular, and movable, unless there 
be adhesions. 

Dirty-yeUow cachectic color of the skiri. 

(Edema of the ankles. 

Tenderness in the region of the stomach — which is increased by 

pressure, and after eating. 
Coffee-gi'ound vomiting— resulting from capillary hemorrhage, 

caused by breaking down of the vascular growth. The 

effused blood is altered by the acid contents of the stomach 

into this black coffee-like mass. 
Hard swelling of the supra-clavicular glands, (may be diagnostic). 

CAUSES OF DEATH. 
From exhaustion (when, prior to death, the tongue becomes red 
and dry, and aphthous deposits occur on the tongue); oedema of 
the legs ensues from obstruction to the femoral vein, showing 
that a clot has formed; frequently from peritonitis (due to rup- 
ture of the stomach); from complications; and secondary diseases. 

DIFFERENTIAL DIAGNOSIS. 

1. From chronic catarrh of the stomach — but the tumor in the 
epigastrium, and coffee-ground vomiting decides it; and there is 
also the general condition of the patient to assist in the diagnosis. 

2. From chronic ulcer of the stomach. 



NERVOUS CARDIALGIA. 



175 



TREATMENT. 

Milk should be taken freely if it can be tolerated, or broth. 
The yolk of an egg (always in small quantities) and red wine. 
For acidity of the stomach, give soda water. The best method of 
administering food or other stimidants is by the rectum, as the 
stomach is thus at rest, and irritation greatly relieved. 

NERVOUS CARDIALGIA. 
DEFINITION. 

Is a painful affection of the stomach, which is not dependent 
upon any perceptible changes in the structure; but upon hyper- 
aesthesia of the pneumogastric nerve, or solar plexus of the sym- 
pathetic. 

ETIOLOGY. 

It occurs in anaemic persons and chlorotic women (from poverty 
of blood); from diseases of the uterus - such as dislocations, flex- 
ions, chronic inflammation, follicular ulcers of the os uteri, and 
inflammation of the ovaries occurring at the period of menstrua- 
tion: from diseases of the brain or spinal cord; from organic 
changes of their pneumogastric or sympathetic nerves; from swell- 
ing of their neurolemma, or tumors pressing upon them; from 
dyscrasia; from excessive acidity, worms, certain medicines, 
beverages, etc. 

SYMPTOMS. 

Paroxysms of severe pain. 

Peculiar feeling of pressure in the stomach. 

Severe griping pain in the pit of the stomach, extending to the 

back. 
Feeling of faintness. 
Countenance becomes shrunken. 
Feet and hands become cold. 
Pulse — small and intermittent. 

Epigastrium — puffed out, or sometimes retracted (with tension of 
the abdominal walls). 



176 



DISEASES OF THE DIGESTIVE TRACT. 



Epigastric pulsation. 

Pains in the thorax (sympathetic) under the sternum. 
Exhaustion— severe (after the attack). 
Eructation of gases and wateiy fluid (after the attack). 
Urine— red color and scanty. 

DIFFERENTIAL DIAGNOSIS. 
It may be confounded with ulcer of the stomach. 

PROGNOSIS. 

Is favorable, unless complicated by some incurable disease. 
TREATMENT. 

For those suffering from anaemia or chlorosis, iron should be 
administered at once in either of the following forms: Ferri car- 
bonas sacch. (British), gr. iv.-x. ; tine, ferri chlor., gr. x.-xxx. ; 
ferri sulph., gr. i.-iv. or Bland's pills, which consist of the follow- 
ing ingredient: Ferri sulph. pulv. ; potass, carb. puree, aa§ss. ; 
tragacanth, q. s. M. fiat pil. xcvi. Take 3 pills three times a day. 

Should this affection occur from malaria, quinine should be 
given. 

DYSPEPSIA. 
DEFINITION. 

Is an impaired state of digestion, arising without any percept^ 
ible change in the structure of the stomach. 

ETIOLOGY. 

It may arise from restricted, too scanty, or abnormally increased 
secretions. It occurs in the aged from lack of material to form 
the necessary secretions, or from diminished excitability of the 
gastric nerves. Over-feeding; too little exercise; excessive study: 
emotional excitement; over-indulgence in spirits^ tobacco, etc., 
may induce it. 

SYMPTOMS. 

Loss of appetite. 
Flatulence. 



HEMORRHAGE FROM THE STOMACH. 



177 



Nausea— (sometimes). 
Eructations — (bitter or acid). 

Tongue — furred, flabby, large, or indented at the sides. 

Headache. 

Pyrosis. 

Heartburn. 

Constipation. 

Hypochondriasis. 

Palpitation of the heart. 

TREATMENT. 

This consists principally in regulating the diet and slight medi- 
cations. The meals should be regular and never hurried over; 
they shoujd be of a plain character, and easy of digestion. The 
food should be properly masticated and the stomach should not 
be over-crowded with food; " it should he taken sparingly ^ Ex- 
ercise in the open air daily is of the utmost importance. Should 
tonics be required, quassia, or Colombo, are the most reliable 
stomachics. In order to overcome constipation, rhubarb may be 
given alone, or, with extract of colocynth, aloes, or podophylli 
resina; or any of the mineral waters may be used. Bicarbonate 
of sodium (gr. v.-x,), or bicarbonate of potassium (gr. ij.-v.), or 
lime water ( 3 ij.)> will be found of great service in case of acidity. 
Should there be any derangement of the liver, a blue pill at the 
onset of the affection may often prevent further trouble. 

HEMORRHAGE FROM THE STOMACH. 
SYNONYM. 

Haematemesis. 

MORBID ANATOMY. 
On post-mortem examination, there is a superficial softening of 
the stomach from capillary hemorrhage, also superficial excava- 
tions in the stomach (called hemorrhagic erosions). The mouth 
of the vessels may be gaping. There are red clotted masses of 
blood in the stomach if death be sudden, or there are brown or 



178 



DISEASES OF THE DIGESTIVE TRACT. 



black clotted masses, as if the blood had escaped slowly and been 
acted upon by the gastric juice. 

ETIOLOGY. 

From rupture of over-filled blood-vessels; from arterial fluxion, 
causing rupture (rare); from venous congestion of the gastric 
mucous membrane; from impediment to the circulation of the 
liver (portal) by blood-clots; from pressure due to cirrhosis of the 
liver, or enlargement of the gall-ducts ; from destruction of the 
capillaries by yellow atrophy of the liver; from rupture of dis- 
eased vessels; from rupture of varices and aneurisms; from ex- 
haustive diseases, as yellow fever, scurvy, typhus, etc. ; from 
improper living, as abstaining from meat and vegetables; from 
erosion or injury to the walls of the stomach, as chronic ulcer, 
cancer, etc.; from corrosive substances; from sharp instruments; 
from blows and kicks; from swallowing of blood in epistaxis and 
haemoptysis ; from miliary aneurism of the gastric artery. 

SYMPTOMS. 
Blood mixed with vomited matter. 

Abnormal sense of pressure about the stomach, and a desire to 

loosen the clothes. 
Peeling of constriction and nausea. 
Paleness. 
Tinnitus aurium. 

Cold skin (if the hemorrhage be profuse). 
Pulse — small (if the hemorrage be excessive). 
Dizziness. 

Painting — (momentary fainting arrests the hemorrhage and favors 

the formation of coagula). 
Nausea — accompanied by a sweet taste in the mouth and by a 

feeling of warm fluid rising in the oesophagus. 
Violent vomiting of blood — partly fluid and partly clotted. 
Passage of blood from the bowels — (black and clotted, or black 

and tar-like). 
Hydraemia and dropsy— from loss of blood. 



CHRONIC ULCER OF THE STOMACH. 179 

DIFFERENTIAL DIAGNOSIS. 
Between haemoptysis and haematemesis. 

PROGNOSIS. 
Favorable, unless complications exist. 

TREATMENT. 

If the portal circulation be obstructed, leeches should be applied 
to the anus, or os uteri. Cold ice-water should be drank, or ice 
eaten, and the epigastrium covered with cold compresses, or ice. 
The patient should lie flat in the bed. If there be syncope, let the 
patient inhale ammonia or eau-de cologne through the nose, or 
throw cold water on the face, and give cold champagne to drink. 

CHEONIC ULCEE OF THE STOMACH. 
VARIETIES. 

See page 12. 

MORBID ANATOMY. 
It occurs in the stomach, or upper part of the duodenum, gen- 
erally near the pyloric orifice, and on the posterior wall. It has 
the appearance of a circular hole (like a terrace) extending from 
the sub-mucous coat toward the serous, with sharp borders as if 
a piece had been punched out. The ulcer is from about a quarter 
to half an inch in diameter usually, and may be round, elliptical, 
or bulging. 

ETIOLOGY. 

Disease of the walls of the vessels of the stomach ; poverty of 
the blood and chlorosis; acute or chronic catarrh of the gastric 
mucous membrane. Long continued pressure, as exists in sewing 
girls, from their position. 

SYMPTOMS. 
Peritonitis — by perforation. 
Haematemesis — by erosion of the large vessels. 
Oppression in the epigastrium — which is increased by eating. 
Pains in the epigastrium — which are steady and increased on 



180 



DISEASES OF THE DIGESTIVE TRACT. 



pressure at one spot. This pain extends toward the back 
(called cardialgia) and occurs soon after meals. If the pains 
occur directly after eating, the ulcer is near the cardiac ori- 
fice. If the pains occur one or two hours after eating, it is 
near the pyloric orifice. 

Vomiting — this, like the pain, indicates the position of the ulcer. 
Severe cardialgia and vomiting usually occurs directly after 
meals. If blood exist, it shows the presence of a chronic ulcer. 
Severe cardialgia may also arise from adhesion of the stom- 
ach to some neighboring organ, impeding its motion. 

Tongue — red and furrowed. 

Increased thirst. 

Habitual constipation. 

Cachectic look and great debility. 

CAUSES OF DEATH. 
Death may occur from perforation of the walls and escape of 
the contents of the stomach into the abdominal cavity, with 
sudden pain, cold skin, small pulse, sunken countenance, collapse, 
and cyanosis (indicating paralysis of the sympathetic system) r 
from hemorrhage of the stomach (rare); from erosion of a large 
artery; or from gradual exhaustion, even when the ulcer has 
healed. 

DIFFERENTIAL DIAGNOSIS. 

From chronic gastric catarrh, where it runs its course ^^^thout 
any pathological symptoms, and from stricture of the pylorus. 

PROGNOSIS. 
Is on the whole favorable. 

TREATMENT. 

The diet should be liquid in character, consisting of milk, bread 
and milk, sour milk, essence of beef, or Trommer's malt extract. 
No vegetables should be allowed. Karlsbad or warm mineral 
spring waters may be prescribed with advantage, but they should 
be properly warmed before drinking. Morphia (gr. i^-^ doses'*. 



CATARRHAL ENTERITIS. 



181 



for the relief of pain. If the epigastrium be sensitive to press- 
ure, then leeches or wet cups may be applied with advantage. 

If there be vomiting, morphia, or ice, or ice-water or creasote 
(gr, iv. to § vi. water in tablespoonful doses), or tr. iodini, gr. ij.- 
iij in sweetened water. Abstinence from all food and rectal ali- 
mentation has been highly recommended. 

DISEASES OF THE INTESimES. 

CATARRHAL ENTERITIS. 
DEFINITION. 

Is an inflammation of the intestines, due to hypersemia, causing 
excessive transudation of a salty fluid deficient in albumen, or an 
abnormal production of mucus and cells. 

~ VARIETIES. 
Acute and chronic catarrhal enteritis; marasmus; typhlitis; and 
perityphlitis. 

MORBID ANATOMY. 

In the acute form. — The changes that take place occur most 
frequently in the large intestine, about Peyer's patches; less so 
in the ileum; and rarest in the jejunum and duodenum. After 
death, Peyer's patches are found to be swollen, as are also the 
solitary glands, causing them to project above the surface of the 
mucous membrane. The contents of the intestines are, at first, 
a serous fluid with detached epithelial and young cells, or a cloudy 
mucus adherent to the walls of the intestines. 

In the chronic form. —The mucous membrane is of a brownish- 
red, or slate color; pufi'ed up and forming rectal polypoid protru- 
sions. Hypertrophy of the muscular walls often exists, causing 
constriction. The mucous membrane may, in some cases, appear 
as if sprinkled with bran (in-dicating a diphtheritic type.) 

There may be ulcerations, either diffused or follicular. The 
diffuse form of ulcer may be due to foreign bodies, or retention of 
faeces; as in typhlitis, where the arrest is most probable to take 



182 



DISEASES OF THE DIGESTIVE TRACT. 



place. The follicular form occurs exclusively in the large intes- 
tine, at the lower part, often causing great destruction of tissue. 

ETIOLOGY. 

It accompanies obstruction of the liVer circulation; disease of 
the respiratory and circulatory organs, causing obstruction to the 
vena cava; from disturbance of the external circulation, causing 
active hypersemia and catarrh, as caused by burns, or sudden ex- 
posure to a low temperature. It occurs in peritonitis, especially 
the puerperal type, which leads to collateral oedema; from col- 
lateral fluxion; from fluxion to the intestinal capillaries induced 
by mental excitement; from local irritation, as in the case of pur- 
gatives; from retention of fsecal matter, causing local peritonitis; 
from epidemics; and, finally, it accompanies various fevers. 

SYMPTOMS. 

In the acute form. 

Accelerated movement of the intestines. 

Diarrhoea — preceded by rumbling; may consist of faecal matter 
mixed with cylindrical epithelial cells, or with undigested 
food. It may be of a greenish color and contain blood. 

Pains in the abdomen. 

Abdomen — prominent. 

Fever— the temperature usually varying between 100°-103°. 
Rumbling and gases in the intestines — showing that the dis- 
ease has extended to the small intestine. 
Constant desire to defecate (if the rectum be involved). 
In the chronic form. 

Secretions are scanty and contain mucus. 
Constipation — is usually present. 
Debility. 
Emaciation. 

Complexion — pale, or dirty-gray color. 
Abdomen — tense and resistant. 
Respiration — impaired. 

Congestion of the brain — may occur, resulting in dementia 
and suicide. 

Secretions from the mucous membrane- may be increased. 



CATARRHAL ENTERITIS. 183 

Peristaltic action — may be increased, (with diarrhoea). 
Death may result from exhaustion. . 
In marasmus. 

Occurs from an exhaustive and obstinate diarrhoea (is most 
common about the end of the first year and after weaning). 

Dejections — are thin copious, and watery; clay-colored; foetid, 
and mixed with undigested food. " 

Child becomes flabby and emaciated ; fat and muscles are ab- 
sorbed, and patient looks prematurely aged. 

Excoriations about the anus. 

Aphthous rash appears in the mouth. 
In Typhlitis. 

This is due to the muscular coat of the intestine losing its 

power of contraction. 
Faeces are collected in the caecum and ascending colon. 
Constipation and diarrhoea alternately occur. 
Passages of mucus or bloody mucous masses are frequently 

present. 
Nausea. 
Vomiting. 

Pain — in the right inguinal fossa. 

Tumor — " sausage shape," and is external to the median line. 

Inflammation — which may extend to the serous covering and 
neighboring organs, causing 

Abdominal tenderness — often indicating Perityphlitis (for 
symptoms see page 187). 

Follicular ulcers— occur in cachectic persons. At first the 
symptoms are those of protracted catarrh of the large in- 
testine; but, after a while, there will be found peculiar 
translucent lumps resembling swelled sago in the mucus, 
and their passage is preceded by tormina with slight 
tenesmus. 

Adhesion of the liver — producing distortions and contractions 
of the intestines. 

PROGNOSIS. 

Is most unfavorable when there are follicular ulcers of the large 
intestine, particularly if the patient be already cachectic. 



184 



DISEASES OF THE DIGESTIVE TRACT. 



TREATMENT. 

If it Occur from constipation— leeches should be applied to the 
anus. 

If from cold - send the patient to bed, give him warm drinks of 
chamomile tea, and apply hot flannels to the abdomen. 

If from a damp climate — the patient should wear woollen 
stockings, which should be changed when the feet get cold. 

If from improper nourishment — the diet should be regulated. 
The patient should be fed on meat broths, and finely-shaved raw 
beef, with a little white bread, and a small quantity of good 
wine. Milk must not be allowed while there is diarrhoea. 

If from retention of fceces — commence with a purgative and 
examine the passages. 

If the passages be bloody, etc. — give one good large dose of 
oil and regulate the bowels. 

If from habitual constipation— administer pidv. digitalis and 
ext. belladonna, gr. ^ to \, in the form of a pill. 

If from typhlitis — prescribe ol. ricini, I ss. -i. If there be no 
vomiting, an enema, with salt, oil, milk or honey, may be used; 
and leeches and hot poultices applied over the right inguinal 
region. 

If from cholera morbus— hot cloths well wrung out should be 
applied to the abdomen, also tannin and nitrate of silver, enema 
of sidphate of zinc, tannin, 3 ss. to § ij. water, or nitrate of silver^ 
gr. ij. to i§ vi. water. In order to armrest the diarrhoea, give mu- 
cilaginous drinks, such as rice, oatmeal, or barley water, etc.; the 
patient should have red wine, infusion of dried whortleberries, 
and roasted acorns. Catechu, 3 ij. ; mucilage, | vi. ; M. Sig., 
3 i. every two hours; or opium, 3 ss. and mucilage § vi. ; or 
a weak solution of ipecac. M. Sig. , 3 i. every hour. 



CHOLERA MORBUS. 
DEFINITION. 

Is that form of acute gastric catarrh which extends to the in- 



CHOLERA MORBUS. 



185 



testinal mucous membrane, and which is characterized by profuse 
transudation of a fluid into the stomach and intes|;ines. 

ETIOLOGY. 

Occurs in the summer, and is usually epidemic. It is some- 
times excited by error of diet. 

SYMPTOMS. 

Come on suddenly, usually at night, with a sense of oppression at 

the pit of the stomach. 
Nausea. 

Vomiting — often profuse in quantity, and possibly projectile in 

character. 
Borborygmi and abdominal cramps. 
Stools — pulpy at first, then thin and liquid. 
Intense thirst. 

Bloody evacuations — in severe cases. 
Urine— diminished in quantity. 
Calves of the legs painfully contracted. 

If evacuations continue, they become like rice-water discharges. 
In children. 

Evacuations — are first acid, green or yellowish, then almost 
white. 

Vomiting — but not of curdled milk — resembles bile. 
Legs are drawn up. 

Convulsions — from anaemia of the brain. 

TREATMENT. 

For the vomiting and diarrhoea, give opium; should they be ex- 
cessive, give gr. ss. doses in the form of a powder. For vomiting, 
ice should be eaten. When there is collapse, stimidants should 
be given inwardly, and hot poultices ap])lied outwardly. For 
diarrhoea, use /S'Q'm&bs' "tinct. opii camp.'" When injurious or 
decomposing food is in the stomach, an emetic should be given, 
and when it has passed into the intestines, rhubarb or compound 
i7ifusion of senna should be administered. 



186 



DISEASES OF THE DIGESTIVE TRACT. 



PERFORATINa DUODENAL ULCER. 
MORBID ANATOMY. 
The most frequent seat of this disease is in the upper horizontal 
portion, but sometimes the descending portion of the duodenum 
is affected. The edges of the ulcer are sharp and not swollen. 
There is a greater loss of substance in the mucous membrane than 
the muscular coat. The floor of the ulcer is som'etimes formed by 
neighboring organs, to which the duodenum has become adherent 
before perforation has taken place. The ulcer may communicate 
with the gall-bladder and produce an external fistulous opening. 
Stricture of the duodenum may follow, or obhteration of the 
ductus commimus choledochus. 

ETIOLOGY. 

This disease is reaUy a necrosis, and a solution of the necrosed 
part of the intestine by the gastric juice. They occur more fre- 
quently in men than in women, while ulcer of the stomach is 
more frequent in women. It is said to be the particular lesion of 
burns occurring over the abdomen. 

SYMPTOMS. 

Are latent until perforation takes place. 

Dyspepsia — (slight, and which has remained unnoticed) may have 
existed. 

Pain — may have occurred in the right hypochondrium for several 

hours after meals. 
Perforation may produce sudden death. 

TREATMENT. 

Strict regulation to the diet should be observed. Alkalies and 
alkaline mineral waters may be taken freely. 

PERITYPHLITIS. 
DEFINITION. 

Is an inflammation of the connective tissue attaching the ctecum 
and ascending colon to the iliac fascia. 



PERITYPHLITIS. 



18T 



MORBID -ANATOMY. 
Abscesses may extend to the region of the kidneys, and, below 
Poupart's ligament, to the inner part of the thigh. The posterior 
wall of the caecum, ascending colon, anterior wall of the abdomen, 
or skin of the thigh, may be perforated, or the contents of the 
abscess may escape into the abdominal cavity, and cause peri- 
tonitis. The exudation may be absorbed, and recovery ensue, or 
the inflammation may lead to necrosis of the inflamed connective- 
tissue. 

ETIOLOGY. 

It occurs in typhus, septicaemia, puerperal fevers, etc., and may 
follow typhlitis. 

SYMPTOMS. 

If from typhlitis, a painful tumor remains lying far back in the 

abdominal cavity. 
Pain — is circumscribed, and a numbness often exists in the right 

leg, from pressure on the nerve -trunks. 
Inability to raise the thigh— because the psoas and iliacus muscles 

are inflltrated. 

Patient lies on the right side, with the body bent forward (so as 

to relax the psoas and iliacus muscles). 
(Edema — from pressure on the veins (sometimes). 
Tumor in the abdomen or thigh — which may be fluctuating, if 

suppuration has taken place. 
Ulceration of the vermiform appendix may occur, resulting in 

symptoms of shock or collapse. 
Inflammation of the transverse colon and sigmoid flexure may 

occur. 

Death — may result from exhaustion, or peritonitis. 

DIFFERENTIAL DIAGNOSIS. 
From typhlitis (see page 183). 

TREATMENT. 

The abscess may be opened, or the contents evacuated by aspira- 
tion. If the contents escape into the ascending colon, recovery 
usually ensues. At the onset of the disease, it is advisable to 



188 



DISEASES OF THE DIGESTIVE TRACT. 



apply leeches several times, and, so soon as fluctuation takes 
place, the tumor should be opened. 

PEEIPEOOTITIS. 
DEFINITION. 

Is an inflammation of the connective-tissue around the rectum, 
which may develop in the course of an acute and chronic inflam- 
mation of the neighboring parts; and as the result of degeneration 
or traumatism of the rectum. 

MORBID ANATOMY. 
Acute periproctitis usually leads to abcesses. The chronic form 
may terminate in thickening and induration of the inflamed con- 
nective-tissue, which ends in partial suppuration, forming fistu- 
lous openings, which are extremely difficult to heal. 

ETIOLOGY. 

It accompanies affections of the pelvis or pelvic organs. It is 
developed sometimes in phthisical patients, 

SYMPTOMS. 

In the acute form. 

Tumor — which is hard and painful. This may be felt in the 

perineum, or in the cavity of the coccyx. 
Infiltration of the connective tissue. 
Patient is unable to sit up. 
Pain — severe (on defecation). 
Tenesmus— severe (in some cases). 

Evacuation of purulent matter and formation of fistulfe. 
In the chronic form. 

Are obscure, till stricture of the rectum is induced. 
If abscess form, there is severe pain, with the above-named 
symptoms superadded. 

TREATMENT. 

Cold may be applied, or poultices, or fomentations. The tumor 
should be opened as early as possible to prevent perforation of the 
bladder or rectum. 



DYSENTERY. 



189 



DYSENTEEY. 
SYNONYM. 

" Bloody flux." 

DEFINITION. 

Is an inflammation of the muscular and mucous coats of the 
large intestines. 

VARIETIES. 

Acute (which is usually epidemic or sporadic); chronic; typhous; 
bilious; malarial; ulcerative; " strumous " or tubercular. 

MORBID ANATOMY. 

There is usually a diphtheritic type of inflammation. The dis- 
eased portions of the mucous membrane are infiltrated by a fibrin- 
ous exudation, and consequent impairment of nutrition and 
sloughing follow. 

In mild cases. — The mucous membrane of the large intestine is 
reddened by ecchymotic injections, and infiltrated by a grayish 
soft exudation which covers the epithelial coat and has the ap- 
pearance of bran. The submucous tissue is swollen and infiltrated 
with serum. The serous coat is cloudy and dull (from oedema). 

In severe cases. — The mucous membrane is changed to a black 
friable charred mass, which may be thrown off. The sub-mucous 
tissue may be infiltrated by a bloody serous fluid, or it may be 
pale. The superficial blood-vessels are consumed to a black pow- 
dered mass, and when this is thrown off, the sub-mucous tissue 
appears infiltrated with pus. The peritoneal coat loses its lustre 
and is injected by dilated capillaries covered by a brownish dis- 
colored ichorous exudation. The intestine contains an offensive 
coffee- ground fluid, and is either in a state of passive dilatation, 
or collapse. The muscular coat is shrunken, pale, faded, and 
easily torn, and the glands are swollen. 

The liver becomes hyperaemic, and abscesses may form within 



190 



DISEASES OF THE DIGESTIVE TRACT. 



it. These are to be explained as the result of the following 
changes: (1) inflammation of the muscular coat of the bowel with 
ulceration; (2) inflammation of the veins, constituting "phlebi- 
tis; (3) blood-clots ("thrombi") form in these veins; (4) suppura- 
tion of these thrombi now occurs, causing their disintegration; (5)^ 
these disintegrated thrombi are carried, as emboli, to the liver by 
the portal vein; (6) infarctions of the liver are thus produced, and 
are followed by suppuration; (7) abscesses in the centre of each 
infarction, or at the seat of obstruction to any of the portal vessels. 
This secondary suppuration depends upon the suppurative origin 
of the emboli in the portal vessels. 

ETIOLOGY. 

Is a disease of hot climates depending on miasm. It occurs 
in the summer and autumn, and often depends upon some blood- 
poisons, such as purpura, cholera, fever, ague, syphilis, etc. It 
may also occur from drinking bad water; from atmospheric 
changes; from inflammation of the colon; from bad hygiene, ex- 
posure, and hardships, as in the army in the field, etc. As iii 
cholera, the stools and water-closets are apt to cause it to spread 
on account of the germs created therein (Niemeyer). 

SYMPTOMS. 

In the acute form. 

Chill — (which is usually preceded by a diarrhoea). 
Fever — slight, with great thirst. 
Countenance — anxious and distressed. 
Anorexia. 

Temperature — elevated. 

Pulse — (in severe cases) rapid, full, and marked; (in slight 

cases) very little excited. 
Tongue — furred. 

Skin — (in severe cases) is very hot and dry; (in slight cases) 
cool. 

Stools — frequent and semi-feculent; small; bloody, slimy, 
offensive, and mixed with mucus and pus and cast off 
epithelium; often "jelly-like," or greenish. 



DYSENTERY. 



191 



Great rectal tenesmus and purging. 

Irritability of the bladder— (strangury or retention). 

Urine— high-colored and scanty. 

Irritation of the vagina— (in female patients). 

Pain griping in character and associated with tenderness on 

pressure (about the colon). 

Constipation, (alternating with diarrhoea) which may be per- 
manent if stricture of the intestine be produced. 

Nausea and vomiting. 

Collapse. 
In the chronic form. 

Is associated with a chronic diarrhoea. 

Rectal tenesmus: — ( f en markei ard distressing). 

Stools — same as in the acute form, and also loose and fre- 
quent. 

Discharges — alvine. 

Pain — griping. 

Emaciation. 

Extensive inflammation of the mucous membrane of the 
colon. 

Examination of the rectum shows ulcers. 
Paralysis of the sphincter muscles may occur. 
Death — may result from paralysis of the intestines. 

PROGNOSIS. 

In the acute form. — Ihe patient may die (if an epidemic exists) 
in a short time. 

In the chronic form. — The prospect of complete recovery is 
doubtful. 

TREATMENT. 

In the acute form. — The patient should be kept in bed, and fed 
on milk, arrow-root, broth, and the whites of raw eggs, etc. 
Tincture opii should be given in full doses; or oleum ricini et opii 
in small doses. 

In the chronic form. — The patient should be put to bed and ke])t 
perfectly quiet; he should be fed in the same manner as in Ihe 
acute form. Full doses of tinct. opii should be given to relieve 



192 



DISEASES OF THE DIGESTIVE TRACT. 



the pain, and oleum ricini et opii in small doses when the dejec- 
tions contain no faecal matter for e day or two. Should the dis- 
charges be excessive and bloody in character, injections of starch 
and laudanum, or starch and iodoform, or a suppository of morph. 
gr. ^, ext. belladonna gr, ss. will frequently arrest this symptom 
in a very few hours. Ipecac (gr. xxx . every half-hour till retained) 
is highly recommended by eminent physicians in the East Indies, 
where this disease is more prevalent than in any other part of the 
world ; and remarkable results seem to have been obtained by this 
treatment. 

ASIATIC CHOLERA. 

MORBID ANATOMY. 
There is, at first, terrible emaciation. The skin is corrugated. 
Black circles will be seen around the orbit, and flattening of the 
eye, from absorption of its fluids. Dryness of the muscles exists 
(from absorption of fluid), and contraction of the muscles after 
death often occurs. Elevation of the temperature takes place 
after death, and the vessels are found to be fllled with coagulated 
blood. 

On opening the body, the right heart will be found filled with 
blood; the organs very dry; and the alimentary canal injected 
and filled with the so-called " rice-water " discharges. 

STAGES. 

1st. Painless diarrhoea. 

2d. Rice-water discharges and cramps. 

3d. Collapse. 

ETIOLOGY. 

The rice germ is claimed to be the cause of this disease; and the 
discharges of the patient are supposed to be contagious. Mental 
influence (fear, etc.) may predispose to it. 

SYMPTOMS. 
\st stage. — Painless and feculent diarrhoea. 
2d stage. — Profuse rice-watery discharges from the bowels. 



CARCINOMA OF THE INTESTINES. 



198 



Projectile vomiting of rice-watery discharges {this is char- 

acteristic). 
Terrific cramps. 

Insatiable thirst, (due to abstraction of water from blood.) 
Terrible emaciation (from extraction of water from the tis- 
sues). 

Premature aging of the patient (from the emaciation and ab- 
straction of fluids from the tissues). 

Stoppage of pulse in the extremities (from thickening of the 
blood due to abstraction of its water). 

High temperature. 

Collapse — the symptoms of which are: 
Complete suppression of urine. 
Cessation of the "rice-water" discharges. 
Insensibility. 

Faeces passed involuntarily and in small quantities. 
Marked cyanosis. 
Sd stage. — Coma and death. 

Duration. — From the time the rice-watery discharges commence, 
24 to 72 hours may elapse before death occurs. 

TREATMENT. 

Stop the diarrhoea, in the first stage, by rest in bed; give large 
doses of opium and remove the patient from all influences favor- 
ing the disease. 

OARCmOMA OF THE INTESTHsTES. 
MORBID ANATOMY. 

It affects the large intestines, especially at the sigmoid flexure 
and rectum; it may also occur in the small intestines. 

The scirrhus form attacks the sub-mucous connective-tissue, 
and, when it has perforated the mucous membrane, medullary 
masses arise from the scirrhus base, and form a ring-like struc- 
ture. The cancer may extend to the peritoneum, the mesentery, 
or neighboring organs. The intestines may become adherent to 
the abdominal walls. Faecal fistula, or perforation of the vagina 



194 



DISEASES OF THE DIGESTIVE TRACT. 



or bladder may occur through breaking down of the cancer (if 
situated in the rectum). 

ETIOLOGY. 

Is obscure. May be due to hereditary predisposition. 

SYMPTOMS. 

Paiii — sometimes sharp and lancinating, but usually dull and con- 
fined to one point. 

Tumor — uneven, nodular, hard, and painful; at first it may be 
movable. 

Habitual constipation, (from degeneration of muscular coat). 

Rapid loss of strength and emaciation. 

Cachexia. 

If it occur in the rectum. 

Pain - severe about the sacrum, extending to the back and 
thighs. 

Dilatation of the hemorrhoidal veins. 
Passage of bloody mucous. 

Habitual constipation or profuse diarrhoea, which cannot be 
stopped. 

Diminution of the rectal calibre (on a digital examination). 
TREATMENT. 

Is palliative. Castor oil may be given daily to evacuate the 
bowels. The food should consist of concentrated broths, soft 
boiled eggs, and milk. If confined to the rectum, surgical inter- 
ference may be demanded. 



INTESTINAL HEMORRHAGE. 
MORBID ANATOMY. 
The mucous membrane is suffused with blood, after capillary 
hemorrhage takes place. The blood is usually of a chocolate- 
brown color, or it consists of a black, tarry mass. Hemorrhoids 
frequently occur, which are at first bluish in color, and with thin 



INTEST1NA.L OBSTRUCTION. 



195 



walls; if they continue for any length of time, and become 
chronic, they lose that bluish look, become hard, since their 
walls become thickened. 

ETIOLOGY. 

From cirrhosis of the liver; erosion of vessels from ulcerations 
(occurring in typhoid fever, dysentery, and tuberculosis of the 
intestines); disease of the walls of the vessels; from escape of 
blood from hemorrhoids, caused by collection of faeces in the 
rectum, producing rupture of the hemorrhoids. 

SYMPTOMS. 

Blood is frequently passed in small quantities, with the discharges 
of the disease with which it occurs. 

Hemorrhoids. — When this complication occurs, there will be pain 
when the stools are hard (if the varices are small); the pain 
may be constant and the patient unable to sit down (due 
often to pressure of the sphincter muscle of the rectum upon 
them). 

Bleeding — occurs during defecation. 

TREATMENT. 

Acetate of lead, with opium, may be given either by the mouth 
or rectum; tannic or gallic acid in the form of a pill or solution; 
in this latter it is used as an injection; or any of the astringents 
may be i-esorted to. Should the patient suffer greatly from 
hemorrhoids, the diet should be regulated. Meat and eggs should 
only be taken once a day, and then only in small quantities; the 
principal diet should consist of vegetables, fruit, rice, etc. Stim- 
ulants must be forbidden. The patient should drink freely of 
water; take long walks, and resort to energetic muscular exercise. 

INTESTINAL OHSTRUOTION". 
• MORBID ANATOMY. 
Above the constriction, the intestines are dilated and elongated, 
and the walls hypertrophied and thickened. The vessels are 



196 



DISEASES OF THE DIGESTIVE TRACT. 



compressed, and great capillary congestion, and probably stasis, 
occurs, and, as a result, mortification of the part occasionally en- 
sues. Below the constriction, the intestines are empty and. col- 
lapsed. 

ETIOLOGY. 

From compression, resulting in contraction and closure, where 
the rectum is compressed by a retroverted uteras, tumors, abscess 
of the pelvic bones, or an overfilled portion of the intestine; from 
structural changes causing constriction, resulting from cicatriza- 
tion of intestinal ulcers (catarrhal, follicular, dysenteric), or 
syphilitic ulcers of the rectum, or carcinoma; from closure pro- 
duced by volvulus, or from entanglement of the mesentery with 
the intestine; from internal strangulation, or incarceration; from 
bands resulting from peritonitis, especially between the uterus 
and its surroundings; from invagination or intussusception, oc- 
curring both in the large and small intestine; from sedentary 
habits; from impaction of faeces: from hernia; from passage of 
gall-stones; from rents in the mesentery, etc. 

SYMPTOMS. 

If partial closure only exist. 

Defecation — tedious and difficult. 

Feet — may be very cold (from impeded return of blood from 

the feet) due to habitual constipation. 
Habitual constipation. 
Menstruation — abundant (in women). 
Frequent erections and sexual emissions (in males). 
Neuralgic pains in the legs — (from overladen rectum). 
Small faeces — (like those of sheep, etc.) in case of stricture. 
Prominence of the abdomen, (from tympanites). 
If complete closure exist. 

Face — distorted and pale and ghastly. 
Hands — cold. 

Pulse — small and imperceptible. 

Prominence of the abdomen — (from typanites). 

Jactitations, or cramps. 

Obstinate constipation unrelieved by treatment. 



WORMS. 



197 



Vomiting — feculent in character. 
Death — may result from general paralysis. 
If closure exist ivith peritonitis. 

Abdomen — puffed up and extremely tense. 
Great pain — on the slightest pressure. 
All movements of the body are avoided. 
Temperature — high. 
Pulse — frequent, hard and tense. 

Respiration — hastened and shallow (from compression of the 

lungs by tympanites, and from the pain). 
Cyanotic look. 

Perforation — especially if the disease occur suddenly, ac- 
companied by sudden pain and symptoms of shock or 
collapse. 
If intussusception occur. 

Sausage-shaped tumor (felt on palpation of abdomen in the 
right inguinal region). 

There may be bloody or mucous passages. 

TREATMENT. 

For constriction. — The diet should consist of eggs, meat, strong 
broths (muscular meat with delicate fibre), and evacuation of the 
bowels by laxatives or enema. 

For invagination. — Gastrotomy should be resorted to. 

WORMS. 
VARIETIES. 

Tcenia solium— (long "tape" or "chain-worm") are usually 
found in the small intestine, but may occur in the large in- 
testine. ^ 

Taenia mediocanellata—are very like the taenia solium. 

BotJiriocephalus latus -broad tape-worm, which closely resembles 
the tsenia solium, and is also found in the small intestine. 

Ascaris lumbricoides — round worm — found in the large and small 
intestine, and may enter the oesophagus, larynx, gall-duct, or 
ductus communis choledochus. 



198 



DISEASES OF THE DIGESTIVE TRACT. 



Oxyuris vermicularis — (" thread-worm ")— found usually in the 
rectum. They may enter the vagina from the anus, and be 
found in that canal. 

Trichoeephalus d^spar—(" whip-worm")— found in the large in- 
testine, especially in the caecum. 

SYMPTOMS. 

In some cases the patient is in no way affected (especially in the 
case of tape- worms), while others may have any of the fol- 
lowing symptoms : 

Severe abdominal pain— (as twistings and turnings). 

Nausea. 

Vomiting. 

Emaciation. Salivation in some cases. 
Diarrhoea — and occasional passage of worms. 
Dilatation of the pupil. 1 

Epilepsy. y most common in children. 

Chorea. j 

Intestinal obstruction (from the round- worm). 

Pruritus ani (especially late in the evening and during the night). 

Incessant desire to defecate. 

TREATMENT. 
Pork must be strictly prohibited. 

For tape-worm. — Filix mas 3 ss.-i. t. d. s. It should be taken 
the first thing in the morning after fasting (the fasting must be 
continued during the whole of the day), and the last dose to be 
taken at bed time. Next morning, after the patient has fasted 
twenty -four hours, a good laxative of calomel, scammony, or | i. 
ol. ricini should be administered. Pomegranate-rind, § iv. to 
O. i.-ij. water, and macerated for twenty-four hours, may be used. 
This should be boiled till reduced to one-half of the quantity; 
then it should be divided into three doses, and taken while fasting 
for twenty-four hours. Should the worms not have passed after 
having taken the third dose, give ol. ricini, 1 i.-ij.; or, oleum 
terebinthi, § i.-ij. mixed with honey; or, ol. ricini at bed-time 
will usually have the effect of removing them. 



INTESTINAL COLIC. 



199 



For round-worms^' — Troches of santonin, ea. gr. ss.-i. 

For ^^thread-worms'''' — large enemata of cold water and vine- 
gar, or corrosive sublimate, gr. § ij. of water (used as an enema; 
have been advocated. 

Prior to administering any of the above remedies, the patient 
should live moderately; his bowels should be kept open; and 
should be made to live on herrings, ham, onions, and salty or 
spicy food. Strawberries, huckleberries, or blackberries may be 
eaten freely. 

INTESTINAL COLIC. 
SYNONYM. 

*'Enteralgia." 

DEFINITION. 

Is a term applied to all painful affections of the intestines, 
which are not caused by inflammation, or textural changes of 
the intestinal walls, but by irritation of the peripheral extremi- 
ties of the intestinal nerves. 

VARIETIES. 

Those which are most common are lead, flatulent, and bilious 
colic. 

ETIOLOGY. 

It occurs in the middle and lower part of the abdomen, from 
structural disease of the ganglia and plexus of the sympathetic 
nerves; from mesenteric neuralgia in females; from worms: from 
eating unripe fruit; from food which is difficult of digestion; from 
accumulation of faeces; hardened faeces; from obstinate consti- 
pation; from fright; from anger; from exposure to cold; from 
affections of various organs, as a morbid state of the liver, kid- 
neys, bladder, testicle, uterus, o-faries, etc.; from a?i abnormal 
state of the blood. 

Lead colic — occurs from poisoning by drinking water carried 
through leaden pipes, producing disturbance of the motor (hyper- 
kinesis), as well as of the sensory nerves (hyperaesthesia^ ; also in 
painters, and those employed in mixing colors. 



200 



DISEASES OF THE DIGESTIVE TRACT. 



Flatulent colic — occurs from distention gf the intestines witl 



Pain— from the navel extending over the abdomen; is of a tearing, 
cutting, pressing, twisting, pinching, or bearing-down char 
acter. Is usually relieved by firm pressure. 

Jactitations — patient seeks relief by compressing the abdomen. 

Hands, feet, and cheeks are cold. 

Features — pinched. 

Countenance — agonized and distorted. 

Pulse — small and hard. 

Nausea. 

Vomiting. 

Desire to defecate^ 

Tenesmus. 

Constipation. 

Lead colic. 

Symptoms are generally preceded by those of lead poisoning. 
Skin — looks dirty. 

Pain — severe (extending to the back and extremities). 
Blue line along the gums and bad breath. 
Sweetish taste in the mouth. 
Pulse — slow. 

Voice — occasionally lost (aphonia). 
Constipation— obstinate (from constriction). 
Abdominal walls strongly contracted, and the abdomen as 
hard as a board. 
Flatulent colic. 

Pain — may be very severe, but relieved by pressure. 

Countenance — expression of anxiety. 

Body — covered with a cold sweat. ' 

Face — pale and distorted. ' 

Pulse — small. 

Nausea. 



gas. 



SYMPTOMS. 




ACUTE PRIMARY PERITONITIS. 



201 



TREATMENT. 

■ Opium should be giV6n in all forms ; it acts as an anaesthetic. 

For lead colic. — Sulphuric acids and sulphates, Glauber's salts; 
iodide of potash, gr. xv. , frequent bathing, and change of clothing. 
The patient, if a painter, should be forbidden to continue in the 
business. 

For flatulent colic. — Warm teas should be given, made of either 
chamomile, valerian, or peppermint ; they should be drank quickly 
and very hot. Enemas should be resorted to ; also flannels wrung 
out in hot water and sprinkled with turpentine, and applied over 
the abdomen. 

For foreign bodies. — 01. ricini, or an enema, should be given; 
or warm compresses may be applied over the abdomen. 

PERITONITIS. 

Is an inflammation of the peritoneum. The peritoneum is the 
largest serous membrane in the body; its office is to facilitate the 
motion of the intestines. Many gallons of fluid may be contained 
in the peritoneum; as many as twenty quarts are often removed. 
Predisposition to peritonitis may occur from any abnormal posi- 
tion of the viscera. 

VARIETIES. 

1. Acute primary peritonitis —which may be due to infection. 

2. Infectious primary peritonitis — which depends upon no local 
cause, except blood changes, which cause its development, as in 
puerperal and scarlet fever, or general blood-infection from 
severer poisons. 

3. Chronic peritonitis. — This form simply differs from the 
acute, in that it is slower of development, and associated with 
some other cause, as cancer, tubercle, and various new growths. 

ACUTE PRIMARY PERITONITIS. 
MORBID ANATOMY. 
The same changes take place in this as in all serous cavities 
which consist of (1) reddening of the surface — from changes in 



202 



DISEASES OF THE DIGESTIVE TRACT. 



the serous membrane and sub serous-tissue — (3) loss of lustre of 
the membrane— (3) shedding of epithelium and an infiltration of 
the epithelial cells — (4) pouring out of a plastic exudation, and, 
underneath this, a layer of embryonic cells — ;5) a serous exudation 
takes place, which washes off the plastic exudation— (6) the form- 
ation of new connective-tissue wliich contains new blood-vessels 
with thin walls — (7) adhesions of the two surfaces, from the form- 
ation of new connective-tissue. When these changes take place 
slowly, there will be found under the plastic layer projecting 
prominences of connective-tissue which may touch each other, 
causing adhesions between the walls of the abdominal cavity and 
those covering the intestines, or, the bands may strike across the 
intestines, causing contraction. A loop of intestines may some- 
times get caught in this stricture, producing internal hernia', etc. , 
when it will be impossible to remove the adhesions without 
lacerating or tearing the intestines. When purulent exudation 
occurs, and it is abundant, it may undergo absorption, or become 
encapsulated. Calcareous exudation may take place in the cavity. 
In addition to the adhesions and bridles, there may be thicken- 
ings of the peritoneum, which, in places, may become from one- 
quarter to one-half inch thick. Adhesions may form over an 
organ, causing contraction, and such pressure on some of the 
organs may produce disordered function. These latter changes 
are most important when occurring in the uterus, since, after a 
while, they may result in constriction of the ovaries and Fallopian 
tubes. 

ETIOLOGY. 

From intestinal obstruction, perforation, and ulceration; typh- 
litis and perityphlitis; perforation of the intestines and stomach, 
from any cause; perforation of the intestines in typhoid fever: 
abscess of the liver; perforation of the diaphragm in emphysema; 
rupture of the bladder or gall-bladder: from strangulated hernia: 
inflammation of the muscular coat of the intestines or stomach: 
rupture of an aneurism into the peritoneum; peri-nephritic ab- 
scess; and, finally, the most common is a change in the vermiform 
appendix, as ulceration and escape of gas into the peritoneal 
cavity. Such escape of gas into the peritoneal cavity from per- 



ACUTE PRIMARY PERITONITIS. 



20d 



/oration is always fatal, and that in a very few hours. In addi- 
tion to the causes above-named, inflammation of the liver; can- 
cerous development of the stomach, from pressure on the peri- 
toneum (localized peritonitis); inflammation of the uterus, or 
ovaries, etc. ; infectious causes, as pyaemia, septicaemia, puerperal 
fever; and the abuse of alcohol (when you may have a general 
peritonitis) may prove exciting causes of this disease. 

SYMPTOMS. 

In the early stage. 

The ordinary duration is from two to eight days — rarely over 
a week. 

Pain — in the right inguinal and umbilical regions, which, for 
a few hours, can be covered with the palm of the hand; 
it gradually extends, in about three or four hours, over 
the entire abdomen. It is increased on firm pressure, es- 
pecially in the region where it commenced (pressure 
should he made with the palm of the hand, and the 
countenance of the patient watched). 

Countenance — pale, anxious, and bears an expression of 
anguish. 

Pulse — accelerated; and, at the end of twelve hours, rises to 
100; is, usually, firm and incompressible. 

Abdomen — distended (after twelve hours), especially in the 
region of the pain. 

Ijegs—fiexed on the abdomen — the patient keeps a position on 
his back, and does not move from it. 

Respimtion — no abdominal movement; only thoracic breath- 
ing is perceptible (as the abdominal pain prevents motion). 

Fear of pain on attempt to move patient. 

Tympanites — (due to accumulation of gas, because the in 
flammation has arrested the peristaltic action of the in- 
testines). 

Vomiting — at the end of t'^enty-four hours. The vomited 
material is regurgitant in character, and the expulsive 
effort increases the pain; there is at first a discharge of 
the contents of the stomach, after which it assumes the 



304 



DISEASES OF THE DIGESTIVE TRACT. 



characteristic spinach-green vomiting; it may be ster- 
coraceous in character. This is an important sign, as this 
does not come on till late; but, should it come on early, 
it indicates that there is extensive intestinal obstruction. 
It may be coffee-ground in appearance (from capillary 
hemorrhage of the stomach), when there is inflammation 
around the stomach obstructing the circulation (this 
may be due to infectious causes). 

Hiccough — may be present, due to the involving of that por- 
tion of the peritoneum covering the diaphragm. 
At the end of the second day. 

Tympanites — (from the same cause as above) is increased. 

Pulse — accelerated 120 (usually small and thready). 

Countenance — more anxious. 

Cyanosis. 

Respiration — hurried and thoracic; may be short and catching 

(due to tympanites). 
Constipation — is a constant attendant of the disease. 
By the fourth or fifth day. 

Patient lies motionless on the back. 
Pulse— very feeble. 
Respiration — short and shallow. 

Mind— clear up to the last ; and, before death, is clearer than 

in any other disease. 
Cyanosis — extreme. 
Perspiration — profuse. 

Collapse — (pulse is imperceptible and respiration more shal- 
low). 

Death — is quiet and peaceful. 
In case of x^erf oration, the disease may not last more than twenty- 
four hours, and is accompanied by the following symptoms: 
Shock — causing collapse. 
Symptoms are rapidly developed. 
Countenance — bears an anxious expression. 
Pulse — almost imperceptible. 
Abdomen — suddenly distended. 
Coldness — suddenly developed. 



ACUTE PRIMARY PERITONITIS. 



205 



Cyanosis — suddenly developed. 
Vomiting— suddenly developed. 
Respiration — thoracic and shallow. 

Death — due to the effects of the shock on the nervous system. 
An apparent reaction may take place, in some cases, and 
life be prolonged for two or three days. 
From the discharge of pus into t\e peritoneal cavity. 

The symptoms are rapid, but not so sudden or rapid as in per- 
foration. 

DIFFERENTIAL DIAGNOSIS. 
It may be mistaken for enteritis; colic; passage of renal, or 
bilious calculi; rheumatism; hysteria; or lead poisoning. 

PROGNOSIS. 

Depends greatly upon the variety. If localized, and seen early, 
the prognosis is good; if irom. ulceration, which excites peritonitis, 
a moderately good prognosis may be given; if from typhlitis and 
perityphlitis, the prognosis is good, if there be no ulceration, 
otherwise it is bad. Perforation of the intestines and entrance of 
gas into the peritoneum is fatal in a, few hours. In cases of trau- 
matism, where the intestines escape injury, the prognosis is good. 
So long as the disease is local in character, and not infectious, and 
no perforation exists, the prognosis is good; but, should it become 
general, even after it has been localized for some time, the prog- 
nosis is grave. 

TREATMENT. 

The opium plan of treatment is the only way of handling this 
disease; in may be given in gr. i.-v. doses, or hypodermically 'n[ xx. 
of Magendie's solution every hour till the respirations reach twelve 
per minute. Opium acts as a controlling influence on peristaltic 
movement, also as an antiphlogistic, and it controls tlie inflamma- 
tory conditions. What are the effects of opium, and what are the 
doses that should be administered? So soon as you obtain the 
proper effect of the drug, you will observe the following symptoms 
in the patient: (1) contracted pupils; (2) suffusion of the eyes; (8) 
dull countenance; (4) profuse perspiration; (5) rash on the nose. 



206 



DISEASES OF THE DIGESTrV'E TRACT. 



which extends down the neck, and is accompanied by intense itch- 
ing; (6) the respiration should grow less and less until twelve a 
minute has been reached, ichen great caution must be observed, as 
the patient is semi-narcotized, and it should always be borne in 
mind that the sloicness of the respiration is the respiration of the 
drug; (7) the pulse is less frequent, having reached 90 in a minute, 
and full and strong, which, previous to the treatment, was hard 
and 110 in a minute; (8) entire abolition of pam; (9) subsidence of 
tympanites; this is the proof of the cure, and the treatment should 
gradually be stopped. 

It is not ihe amount of sleep you have to fear, as the patient may 
b>e so affected that from the very onset, but it is the profoundness 
of the sleep; for, if you cannot rouse him or make him swallow, the 
treatment should be discontinued, and that before he shall have 
reached this condition. If the respirations should ever drop to 
four a minute, then stimulants should be given, and you must 
icait and watch; but, in such a case as this, the heart is your com- 
pass, for you will find it beating steadily at 90, and you are safe. 
Wait until the respiration has reached fifteen to twenty a minute 
before commencing again, but still you must watch the patient, 
and with the utmost care. The bowels will be constipated, on ac- 
count of the peristaltic quietening effect of the drug you are 
using, and, despite the fact that the old women will tell you to 
move the bowels, see that they are not moved for two iveeks. 
After that time, should you deem it advisable to have them 
moved, use the following enema: Warm water, O. i., and glyce- 
rin, § i.-ij., rather than oleum ricini. Never use cathartics. 

Turpentine stupes have been suggested and used over the ab- 
domen. Leeches may be applied over the point where the disease 
starts, and followed by an ice-bag or heat; but there is nothing 
like opium and allowing the patient to remain in peace. 



INFECTIOUS PERITONITIS. 
DEFINITION. 

Is that form of peritonitis which depends upon no local cause 



INFECTIOUS PERITONITIS. 207 

except the blood-changes which tend to favor its development, as 
in puerperal and scarlet fevers, or general blood-infection from 
some severe type of poison. 

SYMPTOMS. 
Chill— long and continued. 

Temperature— high (even before the chill ceases). 
Pulse — 120 to 140 (within the first twenty-four hours), and is fre- 
quent. 

Pain— is first localized, but soon becomes general. 
Expression — anxious. 
Abdomen — greatly distended. 
Vomiting. 

Diarrhoea — whicli is followed by constipation. 

Bladder becomes involved. 

Delirium. 

Cyanosis — after two or three days. 
Death. 

PROGNOSIS. 

Is bad. 

TREATMENT. 

In consequence of the symptoms of this disease being so sudden 
in their nature, opium is not sufficient to control the inflamma- 
tory procBss that takes place. Furthermore, the depression of 
the vital powers is so great that the patient cannot be brought 
properly under its effect. 

It will be necessary to reduce the temperature and pulse, and 
also to sustain the vitality of the patient until he has withstood the 
shock of the pus formation and peritonitis. In order to accom- 
plish this end, quinine should be given in antipyretic dose; and, 
in the event that this drug does not have the desired effect, in 
from twenty-four to forty-eight hours, salicine should be admin- 
istered in its place. In the event of this disease occurring from 
puerperal fever, the saturated tincture of veratrum viride (gtt. 
iv,-v.)with opium should be given in order to allay pain. This 
should be pushed (by giving one to two drops of ver. viride every 



208 



DISEASES OF THE DIGESTIVE TRACT. 



two hours), as, in a few hours or two days at the most, the vera- 
trum viride will lose its power over the heart. Fear of poisoning 
need not be entertained until xomiting takes place, when it will 
be necessary to stop the treatment. Stimulants should be admin- 
istered early and freely in large quantities. These are the only 
four weapons that you will require in attempts to overcome so 
formidable a disease. 

CHRONIC PERITONITIS. 
MORBID ANATOMY. 
Thickenings of the surfaces of the peritoneum take place, which 
are interstitial in character. These thickenings may be one-half 
an inch in thickness, resulting from connective-tissue formation. 
These thickenings are usually associated with cancer and tubercle. 
As regards the tubercle, it is the result of a tubercular inflamma- 
tion which may extend over the whole of the internal, or partially 
over the external surface, resulting in the omentum being full of 
these deposits. Adhesions of the two surfaces and binding of the 
intestines may occur. The gut may be distended or diminished 
in calibre. There may be a sero-purulent exudation in the peri- 
toneal cavity, or the effusion ma}" fill the whole of the peritoneal 
sac and only a slight quantity of pus exist. Should the peritoni- 
tis be local in character, it affects the organs in the vicinity: as. 
for instance, in the region of the liver, it will affect tlie capsule of 
Glisson and produce hepatitis, or the peritonitis may extend up- 
ward from the pelvis to the liver, and involve each organ in its" 
course separately. 

ETIOLOGY. 

It is usually a sequela of the acute form, a low grade of inflam- 
mation, which has been left behind after an acute attack, produc- 
ing interstitial changes. It may also occur from tubercular or 
cancerous development, and from traumatism. 

SYMPTOMS. 
Obscure (if it does not follow the acute form). 



CHRONIC PERITONITIS. 



209 



Pain — if it follow the acute form — which has lasted a long time; 

is increased on motion; and the patient naaybe unable to take 

exercise. 
Loss of strength. 
Emaciation. 
Digestion — impaired. 
Mesenteric glands— enlarged. 

Tumor— (localized, along the line of the intestines). 

Fluid in the peritoneal cavity — (occurring late in the disease). 

If tubercular in character. 

Pain — in the abdomen. 

Digestion— disturbed. 

Diarrhoea — (usually resulting in constipation). 
Abdomen — distended. 

Fever and sweating in the early morning hours. 

Impairment usually of some function; thus the urine may be 
disturbed, or even the stomach may suffer, if the peri- 
tonitis shall have extended so high up. 

PROGNOSIS. 

If it be general in character, the prognosis is bad ; but should it 
be local, the prognosis will depend upon the amount of constric- 
tion. Complete recovery is rarely reached. 

TREATMENT. 

For the general form — (as it is usually accompanied by fluid in 
the peritoneal cavity, with rapid emaciation and cachexia) you 
will only be able to alheviate the symptoms. In order to do this, 
oleum morrhucB and iron and tonics should be given, and the 
nutrition increased. 

For the local form — (provided it be not due to tubercle or can- 
cer) — a permanent counter-irritation should be established by a 
seton or continuous blister, and the nutrition carried to the 
highest possible point. Should there be a large amount of fluid 
in the peritoneal cavity, it must be removed with great care. 



210 



DISEASES OF THE DIGESTIVE TRACT. 



DISEASES OF THE LITER. 



OIEEHOSIS OF THE LIVEE, 
DEFINITION. 

Is a condition characterized by excessive connective-tissue de- 
velopment. 

STAGES. 

1st. Enlargement — dependent upon hypergemia and ceU-prolifera- 

tion of connective tissue. 
2d. Organization of this cell-groivth into new connective-tissue. 
3d. Contraction of the new connective-tissue— iproducing atrophy 

of the liver-tissue from degeneration (on account of pressure 

on the blood-vessels). 

MORBID ANATOJ^IY. 

In the first stage — the liver is uniformly enlarged, firm, tough, 
of a brownish-yellow color, with a sinooth surface and rounded 
edges. The connective-tissue is increased throughout the organ. 

In the second and third stages — the liver is small, of a whitish 
color, the surface is puckered, and the edges are sharp. 

On section — there will be great increase in the connective-tissue, 
the liver substance will appear insular, and of a deep-yellow color. 

ETIOLOGY. 

Alcohol on an empty stomach. The alcohol is absorbed by the 
stomach and taken to the liver, causing irritation of its tissues, 
producing cell-growth. Syphilis: hereditary tendency to cancel 
or gout, etc. 

SYMPTOMS. 

In the first stage. 

Pain— on pressure^ under the ribs. 

Sense of fullness and uneasiness in the abdomen. 

The liver is found to be enlarged (due to ceU growth). 



CIRRHOSIS OF THE LIVER. 



♦211 



In the second stage. 

Liver— (increased in size and smooth in the first stage), after 
which there will be shrinking of the liver, and 
Portal ohstrucfion, as shown by the following symptoms: 
In the inferior mesenteric vein — producing hemorrhoids. 
In the superior mesenteric vein — producing intestinal 

catarrh (due to hypergemia). 
In the splenic vein — producing enlarged spleen. 
In the gastric vein — producing gastric catarrh, gastric 

hemorrhage, rupture, and intestinal hemorrhage. 
From pressure on the radicles of the portal system— pro- 
ducing jaundice, ascites, dropsy, caput Medusae, large 
superficial veins (an evidence of an attempt to estab- 
lish collateral circulation between systemic and portal 
systems of veins). 
Collateral portal circulation (in case of such obstruction). 
1st. Between the superior and the middle hemorrhoidal veins. 
5d. Between new vessels formed by adhesions between the 
liver and diaphragm, or, between the liver and the abdo- 
minal walls. 

3d. Between the phrenic veins and some vessels on the sur- 
face of the liver. 
4th. Between the renal and portal veins. 

5th. By a dilatation of the umbilical vein, thus joining the 
abdominal veins at the navel (caput Medusae). 

Palpation — the liver will be decreased in size, hob-nailed, and 
firm. 

Percussion — diminished area of liver dullness; spleen— en- 
larged. 
\n later stages. 

Ascites — as shown by enlarged abdomen; fluctuation; abdo- 
men becomes flat when the patient is lying down; absence OL 
aortic pulsation; absence of any local tumor; tympanites in 
front, which changes witli the position of the patient; oedema 
of the limbs (from pressure on veins of pelvis and abdomen). 
Jaundice — Intestinal catarrh — Faeces, clay-colored — Anasai'ca 
may be detected. 



212 



DISEASES OF THE DIGESTIYE TRACT. 



CAUSES OF DEATH. 
Death may occur from dyspnoea; repeated hemorrhages from the 
stomach or intestinal canal ; intercurrent diseases, or exhaustion ; 
pulmonary oedema. 

DIFFERENTIAL DIAGNOSIS. 
Between cancer or tuberculosis of the peritoneum. In first 
stage, from waxy or fatty liver, or other enlargements of the organ. 

TREATMENT. 

In the first stage. — Strictly forbid the use of liquors. Leeches 
may be applied at the anus (so as to affect the portal system). 
Saline cathartics may be administered, such as mineral waters, 
and alkaline carbonates (potash and soda), or, if the nutrition has 
suffered, give iron (in the form of iron springs). 

In the second stage. — Alkaline car^bonates should be given to 
overcome the gastric and intestinal catarrh (they decrease the 
toughness of the mucus, and enable the mucous membrane to get 
rid of its mucous coating more readily). Tapping should be 
resorted to for ascites if necessary (always compress the abdomen 
during the operation and afterward by bandages). Improve the 
strength and nutrition of the patient by nutritious diet and pre- 
parations of iron. The diet should consist of milk and eggs, 

^ASCITES. 

The accumulation of fluid in the abdomen may be produced by 
changes which take place in any of the following regions : the 
liver, heart, lungs, kidney, and peritoneum. It may also be due 
to blood-causes. 

MORBID ANATOMY. 
The amount of serum in the abdominal cavity varies from a few 
pounds to forty, or even more. The fluid may be clear or cloudy 
(due to cast off and fatty epithelium). It is usually of a bright 
yellow color, and rarely contains flocculi of coagulated fibrin. 

ETIOLOGY. 

See page 26. 



JAUNDICE. 



213 



SYMPTOMS. 
Rational. 

Feeling of fullness in the abdomen (becoming painful to pressure). 
Slight difficulty on deep inspiration (gradually increasing to dysp- 
noea, as the abdomen enlarges). 
Constipation — from pressure of fluid on the rectum. 
Urine — diminished. 

Obstruction to the circulation of the lower extremities (from pres- 
sure on the inferior vena cava and iliac veins). 

Superficial gangrene — may occur if the venous return be greatly 
embarrassed by the pressure of the accumulated fluid. 
Physical. 

Inspection.— Distention of the abdomen, and a change of its shape 
with position of the patient (due to the amount of fluid present). 

Percussion. — General fluctuation throughout the abdomen. 

Tympanites in front, when the patient lies on the back (on account 
of intestines floating upon the fluid). 

Flatness or dullness at the sides (when the patient lies on the back). 

Displaced cervix (perceived by digital examination) in the female. 

DIFFERENTIAL DIAGNOSIS. 
From ovarian dropsy. — (Bamberger says between the crest of 
the ilium and the 12th rib you find the sound of the large intes- 
tine, which you do not observe in ascites.) From cancer; from 
tuberculosis of other organs (the urine will decide this point, as 
in tuberculosis it is normal, while in ascites the urine contains 
traces of coloring matter of bile or abnormal pigment). 

TREATMENT. 

Tapping should only be performed where life is immediately 
endangered by obstruction of respiration or threatened gangrene 
of the skin. Heim's pills will be found advantageous in these 
cases. 

JAUNDICE. 
VARIETIES. 

Hepatogenous — where there is obstruction to the bile-ducts. 



214 



DISEASES OF THE DIGESTIVE TRACT. 



Hematogenous, or "non-obstructive," where alteration occurs 
in the blood-pigments, causing effects similar to those of bUe 
when absorbed. 

ETIOLOGY. 

See page 25. 

SYMPTOMS. 

Hepatogenous variety. 

Liver and gall-bladder— enlarged. 

Urine— peculiar color (light-brown, like thin beer, or dark, 
like porter). After exposure to the air it becomes green- 
ish, and answers to tests for bile. 

Faeces — light, or clay color, or complete decoloration. 

Skin — golden-yellow (sometimes only slightly tinged); after- 
ward becoming greenish, or even mahogany color. 

Sclerotic of the eye — yeUow. 

Emaciation — rapid. 

Languor and sleepiness. 

Pulse — slow (due to the presence of bile acids in the blood). 
Itching of the skin — sometimes intense. 
Cerebral symptoms — (paralysis, delirium, coma, etc.) 
Hematogenous variety. 

Faeces— may be normal, or very dark color. 

Heart-beat and pulse — irregular and intermittent. 

Urine — discoloration is very slight in proportion to the color 

of the skin, and contains albumen. 
Disturbance of the nervous system. 

CAUSES OF DEATH. 
May occur from intestinal hemorrhage; gastric hemorrhage-^ 
dropsy; or marasmus (senile). 

TREATMENT. 

Improve the state of the patient by proper diet, such as cold 
meat, strong soup (neither fats, butter, nor gravies should be 
allowed) . Slight drastics may be administered (such as inf. sennce, 
rhei, et aloes) to keep the bowels open. When the urine is dimin- 
ished, bitartrate of potash, cream of tartar, or acetate and car- 
bonate of potash may. be given. 



FATTY LIVER. 



215 



FATTY LIVER. 
VARIETIES. 

1. From superfluous fat deposited in the liver-cells (Frerichs' 
fatty liver). 

2. From disturbed nutrition ©f the liver-cells by diseased pa»en- 
chyma (the cells undergoing a retrograde metamorphosis). 

MORBID ANATOMY. 
In some cases the liver will be found enlarged and appear 
flattened, and its edges thickened and rounded ; while in others 
there may be only a slight alteration. The peritor^eal covering is 
transparent, smooth, glistening, and may be traversed by varicose 
vessels. The liver surface may be yeUowish-red or yellow ; it feels 
doughy and pits on pressure. On section, a coating of fat remains 
on the knife-blade. On microscopical examination, the liver lob- 
ules may appear filled with fat globules, or individual cells, may be 
distended by one large drop of oily matter. This infiltration he- 
gins at the periphery of the lobules near the interlobular veins 
rarely extending to the vicinity of the central vein. 

ETIOLOGY. 

From excessive nourishment and no exercise, thus generating 
too much hydrocarbons; from spirituous liquor (retarding the 
transformation of tissue): from tuberculosis of the lungs; from 
incomplete oxidation of hydrocarbons and transformation into 
fat; from tuberculosis of the bones; from tuberculosis of the in- 
testines; from obesity. (Budd and Frerichs say it may be due to 
too much fat in the blood, or, when occurring with tuberculosis of 
the lungs, from giving so much oleum morrhuae. )— Yellow Atrophy. 

SYMPTOMS. 
Rational. 

Extreme debility. 

Gastric and intestinal catarrh. 

Diarrhoea. 



216 



DISEASES OF THE DIGESTIVE TRACT. 



Physical. 
Inspection.— Fullness of abdomen. 

Palpation. — The liver is enlarged and elongated, relaxed and pain- 
less, and has thick edges. The liver of drunkards is thus en- 
larged, and there will be fullness in the right hypochondrium. 

TREATMENT. 

The patient should be made to have proper hours for exercise. 
No afternoon naps or liquors should be allowed. The meals must 
be regular (no gravies, fats, butter, etc.). Karlsbad or "Vichy min- 
eral waters, alkaline saline springs, or plenty of soda water should 
be freely indulged in. 

CANCEE OF THE LIVER. 

Is principally of the medullary type. It may be circumscribed 
or sharply bounded; or diffused between the liver-cells, thus show- 
ing no shai-p line of demarcation. 

MORBID ANATOMY. 

In the circumscribed variety — the tumor is rounded or globular, 
and lobulated; is inclosed in a delicate vascular connective-tissue 
capsule, and, where it touches the peritoneum, is often flattened 
or has a shallow excavation, called cancer navel." The tumors 
may be solitary or innumerable, and may be from the size of a pea 
to that of a child's head, tlius giving the hob-nailed feel to the 
liver. They resemble brain substance, and contain a large amount 
of "cancer juice." They may be milk-white or reddish (on ac- 
count of the number of vessels they contain), or dark-red (from 
effusion of blood), or black (from the amount of pigment con- 
tained). The unaffected portion of the liver is hypersemic (caus- 
ing increased size of the liver), and is usually of a yellow color, 
from compression of the gall-ducts and retention of bile. The 
liver-cells will be found to have undergone fatty degeneration. 
There may be adhesions and thickenings with neighboring parts 
(from chronic local peritonitis). The medullary cancer may soften 
and thus lead to a general peritonitis, or dangerous hemorrhage. 



CANCER OF THE LIVER. 



217 



In the diffused mrie^?/— (infiltrated cancer)— the liver is con- 
verted into a white cancerous mass. Atrophy of the liver-cells 
and obliteration of the vessels and gall-ducts takes place. The 
liver-cells will be found to have undergone fatty degeneration, 
and to be colored by bile. 

Alveolar or gelatinous cancer sometimes extends from other 
organs to the parenchyma of the liver, and may then transform 
the whole into a shapeless mass. There may also be cancer of 
the portal vein. 

ETIOLOGY. 

Is obscure. Is generally due to cancerous diathesis, occurring 
principally in males. Is generally preceded by cancer of some 
other organ. 

SYMPTOMS. 
Rational. 

Obscure at first. 

A sense of pressure and fullness in the right hypochondrium. 
Symptoms of a local peritonitis (early). 

Pain — in the region of the liver (often extending to the right 

shoulder). 
Sensitiveness to pressure. 

Tumor — in the right hypochondrium (detected by palpation and 
percussion). 

Ascites — (from compression of the portal vein). 

Gastric and intestinal catarrh — (from obstruction to the portal 

circulation \ 
Enlarged spleen. 

Icterus — i^from compression of the large bile-duct and the ductus 

choledochus, or catarrh of the bile-duct). 
Distention of the superficial abdominal veins (an evidence of ^oy- 

tal anastomosis, or of severe portal obstruction) 
Dyspeptic symptoms, 

Feeces— colorless (showing defective secretion or escape of bile). 
Urine — peculiarly red or bluish (from abnormal coloring-matter 

contained). 
Cachectic appearance. 
Emaciation. 



218 DISEASES OF THE DIGESTIVE TRACT. 

CEdema of the ankles— (from obstructed venous return from the 
lower extremities). 

Physical. 

Inspection. — The ribs are displaced; and the abdomen may be 
prominent. 

Palpation. — The edge of the organ is indurated, with large and 

small protuberances. 
Peritoneal friction may sometimes be felt. 

CAUSES OF DEATH. 
Dropsy; thrombus of femoral vein; follicular catarrh of the 
intestines. Thrush in the mouth often precedes death. 

TREATMENT. 

This being an incurable disease, the treatment at best can only 
be palliative. Leeches may be applied over the region of the liver 
to alleviate the local peritonitis, and after their removal the sur- 
face should be covered with warm poultices to facilitate the flow 
of blood. The pain should be relieved by opium, and the patient 
supported with good nutritive diet. When ascites occurs, it 
should be removed by tapping, and this should be done early. 

WAXY LIVER. 

SYNONYM. 
** Lardaceous; " " amyloid." 

DEFINITION. 

Is due to a deposit of a substance (resembling amylum or cellu- 
lose) in the liver-cells, and in the walls of the hepatic vessels. 

MORBID ANATOMY. 
The liver resembles fatty liver in form ; it will appear elongated, 
flattened, thickened and sharply defined at the edges, hard as a 
board in consistence, and the peritoneal covering smooth and tense. 
On section, the surface is dry and bloodless, almost homogeneous, 
and possessing a waxy lustre. If a solution of iodine (Lugol's) be 
applied to the cut surface, it will assume a peculiar reddish-brown 
color ; after the addition of sulphuric acid, well diluted with 



GALL-STONES. 



219 



water, there is a violet, and subsequently a blue color produced. 
There may be frequently fatty degeneration of the organ and also 
waxy degeneration.of the spleen and kidney, occurring at the same 
time. 

On microscopical examination, the liver cells appear round and 
enlarged and filled with a translucent homogeneous substance. 
The middle zone of the lobules of the lit-er are chiefly affected: 

ETIOLOGY. 

It occurs in advanced cachexia from scrofulous, cachectic, or 
syphilitic affections; from mercurialism; caries of bones; tedious 
suppuration; tubercular phthisis; and it is induced by malaria. 
There is also a degeneration of the spleen with this disease. 

SYMPTOMS. 

Enlarged liver without pain (chiefly in scrofulous children). 
Ascites — (due to cachexia and the deposit of the amyloid material 

in the coats of the capillary blood-vessels of the Uver, causing 

portal obstruction). 
Spleen — enlarged from waxy degeneration. 
Paleness of skin and mucous membranes. 
Kidneys affected (producing hydraemia). 

PROGr?OSIS. 

Is unfavorable. 

TREATMENT. 

The preparations of iodine, especially syrup, ferri iodidi, are ex- 
tensively used; as are also alkaline baths and preparations of iron. 

GALL-STOKES. 
SYNONYM. 

"Hepatic colic." 

MORBID ANATOMY. 
The gall-stones may be from the size of a pea to a hen's egg and 
vary considerably in number. They may be smooth, round, or 
rough, and some may have convex or concave facets. They are 



220 DISEASES OF THE DIGESTH'E TRACT. 

of low specific gravity, break easily, split when diy, and finally 
dreak down into dust. They may be white, pale-yellow, dark- 
brown, green, or black in color. The majority are composed of 
cholesterin and biliTerdin. bile pigment and carbonate or phos- 
pate of lime. 

There may be slight ulceration of the fundus of the gall-bladder, 
which may lead to perforation, thus entering the peritoneum and 
producing peritonitis. The ulceration may possibly communicate 
with the intestines, or perforate outwardly, after adhesions hare 
formed. The walls of the gall-bladder are often thickened, and 
undergo cicatrical retraction, and biliarj^ calculi may then be found 
imbedded in a chalky mass, inclosed in a shrunken and atrophied 
gall-bladder. Suppurative hepatitis may occasionally be pro- 
duced. 

ETIOLOGY. 

Exciting causes. 

From foreign bodies in the gall-passages (around which chalk 
with bUe-pigment is deposited): from excess of chalk in the bile 
(due to drinking lime-water); from lack of, or decomposition of 
taurocholic acid; from accumulated secretion of bile; from an ex- 
cess of cholesterin and coloring matter. 
Predisposing causes. 

Advanced age; female sex; sedentary habits; habitual constipa- 
tion: over-indulgence in food or drink: cancer of the liver and 
stomach; catarrh, etc., of the gall-bladder, or ducts, interfering 
with the escape of bile. 

SYMPTOMS. 
Begin suddenly and unexpectedly. 
Pain — griping, piercing, and intense: extending from the right 
hypochondrium over the whole of the abdomen to the right 
side of the thorax and right shoulder. It is often localized at 
a point on the free border of the ribs when a line drawn from 
the right nipple to the navel crosses it: and seems to shoot 
through the abdomen, from that point, to the region of the 
back. 

Patient sighs and moans; is doubled up; rolls about the bed or 
floor; and presses on the abdomen. 



HYDATIDS OF THE LIVER. 221 

Pulse — small. 
Skin— cool. 

Face — pale, distorted, and anxious. 
Fainting (sometimes) and exhaustion. 
Tremblings or chills (spasmodic). 

Convulsions of the right half of the body (in rare cases). 
Vomiting — obstinate and sympathetic. 
Paralysis — has been known to occur. 

Permanent closure, inflammation, or ulceration of the excretory 
bile-ducts may follow and produce symptoms characteristic of 
these conditions. 

Jaundice — slight, and usually precedes the attack. 

Constipation — may occur. 

Faeces — may be colorless (from want of bile). 

CAUSES OF DEATH. 
Death may result from biliary obstruction, acholia, marasmus, 
or peritonitis from perforation of the gall-duct. 

TREATMENT. 

Karlsbad, Vichy, or any alkaline water should be given which 
will cause their evacuation, or a preparation of ether, 3 iij. ; oleum 
terebinthi, 3 ij. — dose, 3 ss. in the morning may be given; the dose 
should be increased till one pound of the mixture has been taken. 
Ether, 3 i. ; ol. terebinthi, 3i. may be administered in drop doses; 
and, in order to relieve the pain, tincture of opium (laudanum), gtt. 
xiij. every hour till sleep is accomplished. Morph. acet., gr. | 
every hour or two till slight narcotism is produced, has been re- 
commended. Chloroforin may b3 inhaled. Leeches may be ap- 
plied in the region of the right hypochondrium, after which warm 
compresses may be used to facilitate the flow of blood. After the 
passage of the stone, mild laxatives may prove very beneficial. 

HYDATIDS OF THE LIVER. 

These usually occur in the right lobe, and may reach the size 
of a child's head or even larger. 



223 



DISEASES OF THE DIGESTIVE TRACT. 



MORBID ANATOMY. 
There is a firm, whitish, or yellow fibrous vascular capsule 
which is adherent to the surrounding tissue. Within this capsule 
is a delicate cyst, or bladder, consisting of a hyaline concentric 
layer. The most internal layer of this cyst is studded with minute 
cells (called the germinal membrane or mother cell). "Within this 
mother cell is a quantity of fluid, consisting of a strong saUne 
solution, and floating in this fluid are the daughter-cells (some 
thousands). 

ETIOLOGY. 

From ecchinococci, entering the hepatic lymphatics and develop- 
mg there (Virchow); from ecchinococci, entering the blood-vessels 
of the lirer and developing there (Leukart); from ecchinococci, 
entering the bile-ducts and developing there (Friedreich). 

SYMPTOMS. 
Rational. 

Are latent. 

A sense of pressure and fullness in the right hypochondrium. 
Tumor — in the abdomen yielding an hydatid fremitus. 
Jaundice — shght (is usually present as the result of pressure 

upon the bile-ducts), 
liver — enlarged. 

Ascites — (from obstruction to the portal circulation). 
Spleen — enlarged. 

Gastric and intestinal hemorrhage— (may occur). 
Physical. 

Jnspech'071— reveals a tumor, which is lobulated and usually of 
large size if fully developed. 

TREATMENT. 

Is obscure. They have been opened externally. They may also 
discharge spontaneously into the intestinal canal, thus assisting 
in the diagnosis. They may burst into the peritoneal cavity and 
cause death. 



ACUTE YELLOW ATROPHY OF THE LIVER. 



223 



ACUTE YELLOW ATEOPHY OF TB.E LIVEK. 
SYNONYM. 

Black jaundice. 

DEFINITION. 

Is a combined molecular and fatty degeneration of the organ, 
and the result of a severe constitutional affection. 

MORBID ANATOMY. 

The liver wiU be found sunken against the posterior abdominal 
waU ; it will have a dull yellow appearance ; it will be diminished 
in consistence and also in bulk (occasionally about one-half its 
original size), and also diminished in thickness and appear flattened. 
Its serous covering will be loose and often in folds. The gall-ducts 
and bladder usually contain a scanty mucous secretion ; the con- 
tents of the intestines are often bloody ; the spleen is enlarged ; 
and eccyhmoses are frequent, especially in the peritoneum and gas- 
tric and intestinal mucous membrane. 

ETIOLOGY. 

From continued biliary obstruction -producing distension of the 
bile-ducts from an excessive formation of bile causing continued 
pressure on the liver-cells and consequent atrophy ; from intem- 
perance ; from venereal excesses ;|]from constant exposure to mal- 
arial poisoning, etc. Is a very rare affection, never occurs in 
childhood, more frequently in women and especially during preg- 
nancy. 

SYMPTOMS. 

In the first stage. 

Anorexia. • 
Pressure and fullness in the epigastrium. 
Jaundice — (hepatogenous, but not in all cases). 



224 



DISEASES OF THE DIGESTIVE TRACT. 



In the second stage. 

Jaundice — which increases (hematogenous)' 
Liver — very sensitive to pressure. 
Headache — severe. 

Restlessness and delirium (sometimes). 

Muscular twitchings — may occur (from extention of excite- 
ment to the motor nerves). 
Depression and lassitude — excessive. 
Temperature — very high. 
Pulse — frequent and subsequently small. 
Tongue and gums — dry, and covered with sordes. 
Involuntary evacuations. 

Haematamesis — may occur from destruction of the capillaries. 
Hemorrhage from the bowels — may occur. 
Deep sleep which gradually passes into a profound coma. 
Profuse perspiration. 

Death — usually from the second to the fifth day after the 
coma commences. 
Physical examination shows very rapid decrease of liver dullness, 

the sole pathognomic symptom of the disease. 
Percussion sound — is at first very full in the epigastrium due to the 

diminution in the size of the liver commencing in the left lobe. 

but frequently no trace of liver dullness can be found after a 

few days. There is an increase in splenic dullness which is 

important but does not always occur. 

DIFFERENTIAL DIAGNOSIS. 
From acute hepatitis — from catarrhal jaundice. 

PROGNOSIS. 
The disease is generally a fatal affection. 

TREATMENT. 

Medication is hopeless unless the disease be detected in the first 
stage when saline cathartics may be administered, leeches applied 
at the anus, and cold compresses over the right liypochondrium. 



DISEASES OF THE BEAIN AND 
NERVOUS , SYSTEM. 



CEREBEAL HYPEREMIA. 



ETIOLOGY. 
Active or Fluxionary Hyperemia. 

Increased Hearfs Action. 

Fi'om augmented energy, as in fevers, or bodily or mental 
excitement. — From cardiac hypertrophy, (as an independent 
disease). — From cardiac hypertrophy accompanying an 
obstructed circulation (compensatory). From too slight 
resistant power of afferent blood-vessels whether congenital 
or acquired (" Rush of blood to the head"). 

Collateral Fluxion or increase of Lateral Pressure i7i the carotids. 
From obstructed escape of blood from the aorta into other 
branches. — From conatrctions or closure of aorta (due to 
compression of adominal aorta, and its branches, from dis- 
tended intestines and exudations). — From obstruction of cuta- 
neous circulation, as in cold stage of intermittent fever. — 
From severe cold. — From severe muscular exercise, by press- 
ure of muscles on the capillaries. 

Paralysis of Vaso-motor nerves (of cerebral vessels). 

From section of cervical portion of the sympathetic. — From 
use of spirituous liquors. — From poisons. — From excessive 
mental emotions and activity (especially). — Atrophy of the 
brain following apoplexy. 

Passive or Congestive Hyperjemia. 

Compression of the Jugulars or Superior Vena Cava. 

From strangulation. — From enlarged thyroid glands. — From 
enlarged lymphatic glands, affecting the jugulars. — From 
aneurism of the aorta. — From enlarged glands, affectiag the 
superior vena cava. 

Energetic Expiratory Movements ivith Glottis contracted. 

From coughing, straining, playing wind instruments, etc. 



226 



DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 



Non-compensated Valvular Lesions of Heart. 

From capillary hyperaemia (since over-filling of the veins ob- 
structs the flow from the capillaries). — From impeded return 
of venous blood. — From valvular disease of right heart, pre- 
venting escape of venous blood, and increasing amount of 
blood in skull. — From valvular disease of left heart (causing 
delayed circulation in the lungs). 

Lung Affections (interfering with- circulation). 

Emphysema (especially last stage), producing general cya- 
nosis of brain. — Pleuritic effusion. — Cirrhosis of lung. 

Plethora (by increasing the amount of blood). 

From a too free supply of food and drink (having a tendency 
to apoplexy). 

SYMPTOMS. 

Headache — more or less severe (due to irritation of filaments of 

the fifth nerve going to the dura mater). 
Feeling of constriction in the head. 
Grreat sensitiveness to bright lights and loud noises. 
Flashes before the eyes. 
Tinnitus aurium. 
Dizziness. 

Nervous irritability or depression — patient is annoyed by the 

slightest irritation. 
Face and conjunctiva — may be reddened. 
Temperature — may be elevated. * 
Pulse — full and rapid. 
Hallucinations and illusions. 
Respiration — retarded. 

Sense o* formication in the lower extremities. 

Slowness and sluggishness in the movements of the patient. 

Delirium — (in the asthenic type). 

Fullness of the meningeal veins. 

Insomnia or disturbed dreams. 

Restlessness. 

Vomiting. 

Convulsions— may occur, with loss of consciousness. 
Paralysis. 



ANEMIA OF THE BRAIN. 



327 



PROGNOSIS. 
Depends upon the cause. 

TREATMENT. 

As this is simply a symptom which accompanies so many dis- 
eases, the cause must therefore be treated. General and local 
blood-letting, cold to the head and derivation to the skin and 
lowels have enjoyed a good reputation, yet, neither the one nor 
the other must be used indifferently. Should there be collateral 
fluxion to the brain, the obstructions to the circulation, by which 
the pressure of blood in the carotids is increased, must be re- 
moved. In adults, suffering from constipation, headache, tinni- 
tus aurium, etc., and especially in children, where constipation is 
accompanied by convulsions, evacuation of the intestines by laxa- 
tives or enemata of vinegar and water frequently has a wonder- 
ful effect. Should these means prove insufficient, depletion in the 
adult, and leeches applied to the head in children, should be re- 
sorted to if symptoms of depression occur. 

In congestive hyperaemia, resulting from compression of the 
jugular veins or vena cava, venesection or leeches behind the ears 
may be resorted to if the obstruction to the current of blood can- 
not be removed. 

OF THE BRAIN. 
MORBID ANATOMY. 
If dependent upon embolism, emboli are almost always found 
in the left fissure of Sylvius (producing hemiplegia during life). 
The brain is discolored, and the gray substance is paler than 
normal, and softened in the region of the embolus. 

ETIOLOGY. 

It may occur from spasmodic contraction of the arteries, or be 
due to obstruction to the carotid and vertebral arteries (by an 
embolus or as the result of thrombosis): to obstruction to the 
arteria fossae Sylvii (by an embolus or thrombus), causing obstruc- 
tion in the circle of Willis; to obstruction from pressure, as in 



228 



DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 



the case of a tumor, or the presence of oedema around an apoplec- 
tic clot, or a point of inflammation, or softening; from com- 
pression of the capillaries by extravasation of blood, tumors, etc. ; 
and from diseases contracting the space within the skull, as exos- 
tosis, cancer, etc. 

SYMPTOMS. 

Premonitory symptoms. 

Disturbance of the circulation (probably due to the contrac- 
tion of cerebral vessels, or to senile cerebral atrophy). 

Pain — in the head. 

Dizziness. 

Tinnitus aurium. 

Flashes appear before the eyes. 

Loss of memory and power of thought. 

Patient is apathetic and indifferent. 

Inclination to sleep (which is disturbed and uneasy). 

Aphasia— which is usually of the amnesic variety (in case of 
an embolus of the left middle cerebral), and hemiplegia. 

A sense of formication, or of certain limbs going to sleep. 

Contraction or paralysis of the limbs. 
Of disease of the posterior cranial fossa. 

Pains — in the back of the head (from filaments of the fifth 
nerve to the tentorium cerebelli). 

Sympathetic vomiting. 

Peculiar dizziness (when moving about). 

Diminution of sensibility and motor power (but not complete 
paralysis). 

Impaired articulation and deglutition. 

TREATMENT. 

Promises very little, if any benefit, should thrombosis and em- 
bolism occur, as therapeutic remedies cannot remove the obstruc- 
tion, and absorption is all that can be hoped for. Should there be 
no symptoms of irritation, a strengthening and stimulating treat- 
ment is indicated; but, if there be symptoms, such as severe head- 
ache, contractions, etc., cold has been suggested, and al^o the ap- 
plication of leeches behind the ears." 



APOPLEXY. 



229 



APOPLEXY. 

DEFINITION. 

A condition characterized by complete functional inactivity of 
the brain ; produced either by swelling of the vessels (miliary 
aneurism) or extravasation of blood into the brain-substance. 
Symptoms of a similar character may be produced by serous effu- 
sions, or by organic diseases of the brain. 

VARIETIES. 

Sanguineosa; serosa; and nervosa; the first being the most 
common. 

MORBID ANATOMY. 
There may be small, numerous, closely packed effusions, which 
denote capillary rupture, or a larger quantity of blood, denoting 
rupture of the larger vessels. If it should result from capillary 
rupture, the brain-substance is dotted over with dark-red punctate 
extravasations; it may cause the brain-substance to appear of a 
yellow or reddish color, and to become moist, relaxed, or broken 
down (causing red softening). Small clots press on the brain 
filaments, but large clots break up and mix with the brain- 
substance. The blood may escape into the ventricle, or even in 
the sub-arachnoidean space. The most frequent seats in which the 
clots are found are in the corpus striatum, the optic thalamus, the 
peduncle of the brain, and the large medullary masses of the 
hemispheres. The clot, which varies from the size of a hemp- 
seed to that of a man's fist, consists of blood and broken-down 
brain-substance, which may be either fluid or partly coagulated. 
The clot is often inclosed by a new formation of connective-tissue, 
starting from the neuroglia, there is also a delicate connective-tissue 
which surrounds the walls and traverses the clot. After a time 
a cyst forms, inclosing the clot, and the serum may ultimately 
be absorbed. The injuries to the brain-substance often produce a 
gradual diminution of mental power, said to be due to atrophy 



230 



DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 



of the brain-substance, associated with degeneration, extending 
into the spinal medulla. 

ETIOLOGY. 

It occurs principally from rupture of the smaller arteries or 
capillaries from structural disease (endarteritis); from increased 
pressure (due to a fatty degeneration of the walls of the arteries), 
in cachectic, badly nourished, chlorotic persons (producing fragil- 
ity of the vessels) ; from small dissecting aneurisms ; from weak- 
ness of the cerebral vessels (as in typhus fever and scorbutus) ; 
from gradual atrophy of the brain-substance ; from plethora 
(where there is a morbid fragihty of the vessels); and from in- 
creased pressure and existing atheromatous changes. 

It may occur at any age and time of the year, and without 
any appreciable existing cause. 

SYIVIPTOMS. 

Premonitory symptoms. 

Headache — or fullness of the head. 
Tinnitus aurium. 
Flashes before the eyes. 
Dizziness. 
Insomnia, 
Formication 
IrritabUity. 

Symptoms of attack (modified by seat and extent of hemorrhage). 

Fit — (which is due to anaemia of the brain-substance from 
sudden compression of the capillaries), comes on at the 
onset, or may not come on till after paralysis has oc- 
curred, or it may come on suddenly with coma, or rapidly 
developing coma. 

Breathing — loud and stertorous. 

Respirations — diminished. 

Vomiting — at the commencement of the attack. 
Pulse — very slow. 
Pupils — irregular. 
Pulsation of the carotids— more marked than in health. 
Aphasia— (of the amnesic type) may occur, if Broca's centre 
be involved frontal c:^nvolut:(m\ 



due to general or partial 
hyperaemia of the brain. 



symptoms 
of cerebral 
compres- 
sion. 



APOPLEXY. 



231 



Temporary paralysis of muscles, or any group of muscles — 
may exist, (the various types of monoplegia). 

Paralysis of the arm and leg of one side (hemiplegia) — from 
destruction of the corpus striatum, optic thalami, or 
peduncles of the brain on the opposite side, by a clot. 

Loss of will and previous capabilities of thought. - 

Facial paralysis of Bell — where the corner of the mouth 
hangs down on the affected side, and is raised on the 
sound side — Tongue, if protruded, goes toward the paral- 
yzed side. — Eye of the affected side cannot be closed. 

Anaesthesia — from compression of the sensory nerve fibres of 
the brain (posterior third of internal capsule). 

General convulsions — (may occur) if the clot acts as an irri- 
tative lesion to the motor area of the cortex, and does not 
affect the deeper parts. 

Death — may result from hemorrhage into the pons, if the 
hemorrhage be of considerable amount ; from hemorrhage 
into the medulla, if the hemorrhage be slight. 

Instead of improvement in twenty-four hours, the symptoms 
usually increase, if the clot be large or the damage to the 
brain be extensive. 

DIFFERENTIAL DIAGNOSIS. 
From embolism ; cerebral softening ; and all causes of coma. 
PROGNOSIS. 

This depends on the extent of the extravasation and its seat. 
One attack is, usually, soon followed by another, since the vessels 
of the brain are diseased. 

TREATMENT. 

During the attack — venesection may be performed, but only if the 
heart-impulse be strong and the sounds loud, with a regular pulse 
and no oedema. Stimulants should only be administered if weak 
heart and irregular pulse occur. Mustard plasters may be ap- 
plied to the chest and calves of the legs. The skin should be 
rubbed vigorously. Dash cold water on the breast, or drop melted 
sealing wax on the chest (Niemeyer). 

After the fit. — The diet should be mild. The bowels should be 



232 



DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 



kept open. Cold should be applied - to the head, leeches behind 
the ear, and the induced current to the paralyzed muscles. 

MENINGITIS. 
VARIETIES. 

See page 9. 

ACUTE MENINGITIS. 
SYNONYM. 
" Simple meningitis of the convexity." 

DEFINITION. 

Is an acute form of inflammation of the coverings of the brain, 

MORBID ANATOMY. 
On removing the calvaria, it will be found to be adherent to the 
dura mater. The brain-substance will be of a greenish color, due 
to the infiltration of serum, fibrin, and pus into the meshes of the 
pia mater. It is most marked at the convexity and along the 
course of the vessels. The dura mater will be found thickened 
and slightly adherent to the calvaria. The arachnoid is opaque, 
its surface roughened, slightly adherent to the dura mater, and 
covered with punctate spots. The cerebral vessels and their 
branches are injected and prominent. The ventricles will be 
found empty. The brain-substance will be softened, in various 
parts, from the pressure of the exudation. The sulci will be deep- 
ened and the convolutions sharpened. 

ETIOLOGY. 

It usually occurs between the ages of 18 and 20, and 40 and 50, 
and i^ more frequent in men than in women. It is rarely an in,- 
dependent disease; but is usually secondary to some injury, dis- 
eases of the skull, and dura mater, or other diseases. It occurs 
in cachectic persons from long exhaustive illness. It may occur in 
pneumonia, pleurisy, acute exanthematous and infectious diseases 



ACUTE MENINGITIS. 



238 



(typhus especially, from the tendency toward cerebral engorge- 
ment), andBright's disease; from exposure of the head to the rays 
of the sun, or very low temperature; from the misuse of liquors; 
from caries of the petrous portion of the temporal bone, or from 
over-taxation of the mental faculties. 

STAGES. 

1. Headache. 3. Delirium. 3. Coma. 

SYMPTOMS. 

Stage of headache (lasts from 24 to 72 hours). 
Rarely ushered in with a chill. 
Headache — is severe and increases. 
Photophobia. 

Pupils— contracted (due to congestion of the brain, producing 

reflex manifestations). 
Pulse — elevated (120 to 140), small, hard, and regular. 
Abnormally acute. sense of hearing. 
Intolerance to noises. 
Nausea and vomiting (possible). 
Constipation or diarrhoea (may occur). 
Tongue — moist and coated. 
Gait — unsteady. 

Face — pale at first, but afterward flushed. 
Stage of delirium (lasts from a few hours to three days). 
The delirium may be muttering or active. 
Patient is constantly trying to get out of bed. 
Talks to imaginary objects or persons. 
Pupils— unequally contracted. 
Pulse— frequent, intermittent, or irregular. 
Constipation. 
Insomnia. 

Alternating flushes and pallor of the face. 
Convulsions (may occur). 

Patient becomes gradually stupid, and after three days coma 
usually takes place. 



234 



DISEASES OF THE BRAIN AND NERVOtrS SYSTEM. 



Stage of coma. 

Pulse — slow 40-60 (in the first stage, afterward becoming 
very rapid). 

Temperature — may fall below normal, but rapidly rises. 

Loss of sensation and voluntary motion. 

Delirium — may be slight and muttering. 

Pupils — dilated (from inter-cerebral pressure) in this stage. 

Flapping of the cheeks (in the first pail; of the coma). 

Face— turgid. 

Constipation. 

Eyes — wild and brilliant. 

Sphincters — may be relaxed. 

Blueness of the fingers and lips. 

Profuse perspiration. 

Eetention of urine. 

Capillary circulation — poor. 

Respiration — sighing and marked. 

Heart's sounds — indistinct. 

Tongue — dry and brown (from not breathing through the 
nostrils). 

Patient passes into collapse, finally resulting in death. 

DIFFERENTIAL DIAGNOSIS. 

This disease may be confounded Avith typhus fever ; acute 
uraemia; small-pox (for the first few days); or delirium tremens. 

In typhus fever — the delirium comes on late in the disease : the 
pulse will be frequent and small; and the countenance dull and 
heavy. 

In acute urcemia — there will be the small amount of urine, con- 
taining albumen and casts: and the pulse will be soft and slow. 

In small-pox — you will have pain in the head, back and loins, 
the eruption occurring along the roots of the hair, and at the alas 
of the nose after thirty-six hours. 

PROGNOSIS. 

Is unfavorable, especially when pus, serum, and lymph are de- 
posited in the arachnoid. 



SUB-ACUTE MENINGITIS. 



235 



TREATMENT. 

Various methods have been suggested, but it has been found of 
late years that the best treatment is to keep the patient quiet in 
bed, and relieve the pain by hypodermics of morphine, 

SUB-ACUTE MENINGITIS. 
MORBID ANATOMY. 
In this form of meningitis no pus is exuded, and the cell exuda- 
tion is slight, but there is a sero-fibrinous exudation under the 
arachnoid into the meshes of the pia mater. Floccules of lymph 
will also be found along the line of the vessels. The arachnoid 
will have lost its brilliancy and become opaque and thickened, 
and when held up to the light, white spots may be seen, chiefly in 
the lines of the vessels, together with spots of ecchymosis. The ves- 
sels may be engorged. Congestion may occur, but this will de- 
pend upon the amount of serous effusion present. Effusion into 
the ventricles may occur. It should he borne in mind that no 
effusion is inflammatory unless it he found to contain fibrin^ and 
the arachnoid he thickened and opaque, with little spots of ecchy- 
mosis and enlargement of the vessels. 

ETIOLOGY. 

It may be secondary to Bright's disease; typhus fever; malaria; 
or any exanthematous disease. When it occurs in Bright's, the 
slow pulse usually precedes the coma. 

STAGES. 

Same as those of the acute form. 

SYMPTOMS. 

' Stage of Headache. 

Is not present, as a rule; or if it should be, is not prominent. 
Stage of Delirium — (lasts from a few hours to one or two days). 
DeUrium— is not active, but stupid and senseless. Patient 
gets out of bed and is easily put back again, and then gets 
out again after a short while. 



236 DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 

Stage of Coma (comes on rapidly). 

Pulse— slow, at first, afterward becoming very frequent (due 

to a failure of heart's power). 
Respiration— sighing. 
Tongue— dry, dark-brown. 
Pupils — dilated. 
Collapse and death. 

PROGNOSIS. 

About one-third of the cases recover. Should it be due to 
Bright's disease, it will be progressive, and terminate in death. 
If to pygemia, it will be slowly fatal. 

TREATMENT. 

Should it occur in connection with any of the fevers, the patient 
should be kept in bed, with the head slightly elevated. Only one 
person should be in attendance, and the room kept perfectly dark 
and quiet. Counter-irritation should be applied to the feet in the 
form of a mustard foot-bath; the feet should be kept in it for 
about one hour or until redness of the surface is produced. Should 
there be constipation, cathartics are indicated. Blisters and 
counter-irritants may be applied to the back of the neck. Stimu- 
lants may be administered freely if' it occur from typhoid or typhus 
iever. Iodide of potassium (in gr. xx. to xxx. doses) every three 
hours are especially indicated should syphilis be suspected. 

CHRONIC MENINGITIS. 
SYNONYM. 

" Pachy-meningitis." Is termed externa and interna (or haema- 
toma of the dura mater) according as it may effect the external 
or internal surface of the dura mater. 

MORBID ANATO]\rY. 
In the externa — the dura mater is thickened and opaque (from 
an increase of connective-tissue development) and adherent to the 
cranium. It ii red and vascular. Pus will be found between the 
dura mater and the skull. Pia mater may be greatly inflaire'l. 



CHRONIC MENINGITIS. 231 

In the interna — ^there may be hsematoma (resulting from inflam. 
mation) between the dura mater and the cranial bones, having its 
origin in the dura mater or underneath the archnoid. The hsema- 
toma is produced by rupture of the small vessels in the new con- 
nective-tissue. There may be a destruction of the arachnoid and 
the formation of abscesses containing three or four ounces of 
pus, resulting in pysemia. 

ETIOLOGY. 

Advanced stage of syphilis; caries or fissure of the petrous por 
tion of the temporal bone; suppuration of the orbit; extension oJ 
inflammation from the internal ear; chronic alcoholism; chronic 
Bright's disease. 

SYMPTOMS. 

Present in all varieties. 
Are often vague. 

Pain in the head — which is localized, and increased by exer- 
cise, mental labor, excitement, etc., may usually be 
detected, at the vertex and forehead. 
If due to alcohoUsmus. 

. The vision and special senses are disturbed. 
Tinnitus aurium. 
Gait —unsteady. 
Hypersesthesia or anaesthesia. 
Delirium ~ slight. 
Talks— incoherently. 

Sleep is disturbed, at first; then the patient becomes disposed 

to sleep and gets stupid. 
Inequality of the pupils — (or may be contracted). 
Slight facial paralysis. 
If due to otitis media or acute otorrhcea. 

Perforation of the tympanum and discharge of pus from the 
ear. 

Slight stiffness of the muscles at the back of the neck. 

Pupils — slightly irregular. 

Vomiting. 

Temperature — slightly below normal. 



238 



DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 



Pulse - about 80 or a little below normal, and may be inter- 
mittent or irregular on movement. 
Peculiar expression of countenance— (pyemic in character). 
Skin — pale, dingy yellow. 
Face— puffed. 

Delirium of an hysterical type — may occur. 
([ffrom syphilis. 

Patient wanders, gets out of bed, and there may be facial 
paralysis (from inter-ceiebial pressure). 
In all cases having cerebral symptoms assuming an hysterical 
type, with an intermittent pulse, and discharge from the ear, 
chronic or pachy-meningitis may always be anticipated. 

PROGNOSIS. 

Is usually unfavorable. 

TREATMENT. 

Is usually hopeless, if the disease be extensively developed. 

ACUTE HYDROCEPHALUS. 
SYNONYMS. 

Tubercular or basilar meningitis, or " dropsy of the brain." 

MORBID ANATOMY. 

There is congestion on the surface of the brain, with a serous 
effusion extending into the ventricles. At the base of the brain, 
there is a sero-fibrinous exudation (sometimes sero-purulent) which 
is most marked at the optic chiasm and fissure of Sylvius. The 
arachnoid is thickened and opaque, and the dura mater is also 
opaque. The convolutions are flattened, and the sulci deepened. 
Nodules will be found in the meshes of the pia mater (tubercle), 
both of the brain and spinal cord which vary in size from that of a 
pin's head to a pea, and which later on, may undergo degeneration. 

The characteristic lesion is an effusion of serum and lymph, and 
a tubercular deposit at the attached surface of the arachnoid 



ACUTE HYDROCEPHALUS. 



239 



(most marked at the optic commissures and island of Reil) at the 
base of the brain along the fissures, causing thickening and extra- 
vasation into the pia mater. 

ETIOLOGY. 

It occurs in children of a scrofulous diathesis between two and 
five years of age; in old age; in alcoholismus; and from bad food 
and air; and want of cleanliness. This disease usually lasts from 
ten to fourteen days or even three weeks. 

STAGES. 

This disease has three stages: — 1st. Delirium. 2d. Coma. 3d. 
Collapse. 

SYMPTOMS. 
Premonitory symptoms — (of great diagnostic value). 

Change in the disposition of the child, stops in his play, and 

wants to be held. 
Rests his head on the mother's knee or on his own hand. 
Gnashes his teeth in his sleep. 

Thumbs — flexed on palms of the hand during sleep. 

Ptosis (the upper lid falling, giving the eye the appearance of 

being half closed). 
Head thrown back and bored into the pillow. 
Moans during sleep and rolls the head from side to side. 
In the stage of delirium. 

Patient is fretful and uneasy. 

Pains in the head — patient puts the hand to the head. 

Pupils — contracted. 

Photophobia. 

Patient answers slowly but rationally. 
Vomiting — is projectile. 
Jactitations. 

Pulse — firm, hard, and regular (110 to 140); can be accelerated 

by very slight excitement. 
Abdomen — retracted . 

Temperature — may be remittent or normal. 
Respiration — sigh ing. 



2iO DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 

In the stage of coma. 

Disposition to sleep — (after two or three days). 

Involuntary evacuations. 

Pupils — do not respond to light (as at first). 

Pulse— becomes slow (60 to 70). 

Hydrocephalic cry. 

Convulsions — probable. 

Eyebrows —contracted. 

Slight paralysis — (may occur). 

Picking at the bed-clothes. 

Head rolls from side to side. 

Lethargy increases gradually. 
A strange remission may occur before the third stage, wherein 
the child may appear to be recovering; it is only temporary, how- 
ever, as the patient passes into a deeper coma. 
The stage of collapse. 

Pulse — increases (160 to 200), small, frequent, intermitting, 
and not easily compressed. 

Paralysis— may occur of one arm or leg, or even hemiplegia 
may be developed. 

Strabismus. 

Sphincters — relaxed. 

Eyes — rolled up. 

Head— rolled to one side. 

One-half of the body may be hot, and the other half cold. 

Pupils— irregularly dilated. 

Inspiration —rapid . 

Expiration — imperfect. 

Imperfect capillary circulation. 

Death— frequently occurs with convulsions. 

PROGNOSIS. 

About seven-eighths of the cases die, and those who recover are 
usually crippled. 

DIFFERENTIAL DIAGNOSIS. 
It may be confounded with infantile remittent fever; Bright's 
disease (in children); spurious hydrocephalus. 



CHROKIC HYDROCEPHALUS. 



241 



TREATMENT. 

The patient should be kept in a dark, quiet, well-ventilated 
room. The diet must consist of milk,^or milk and lime-water. A 
piece of ice should be put in a bladder and laid on the pillow a 
short distance from the head. The feet should be placed in a 
mustard foot-bath. Blisters may be applied early behind the 
ears. Iodide of potassium may be given in full doses, but it has 
no effect. Small doses of morphine (gr. have been recom- 
mended by Hasse. In order to prevent this disease if possible, 
especially if the parents are of a tubercular diathesis, the child 
should be sent at once into the country and kept there for at least 
two years. A good strong wet-nurse should be obtained, or else 
the child should be fed on milk from the bottle for the first eigh- 
teen months; no mixed diet should be allowed. Cod-liver oil 
should be given continually especially during the cold months. 
Care should be taken to see that the child is properly clad. If at 
the end of two years the child begin to be fretful, the whole habit 
of life should be immediately changed. 



CHRONIC HYDROCEPHALUS. 

VARIETIES. 

1st. Intra-uterine. 2d. When it occurs after birth, before 
closure of the sutures. 3d. When it occurs some time after birth, 
when the sutures have closed. 

MORBID ANATOMY. 

There is failure of the fontanelles to close; enormous growth of 
the cranium quite out of proportion to the face; sei)aration of the 
sutures; and fluctuation between the fontanelles. There is an 
accumulation of fluid in the ventricles and in the meshes of the 
pia mater. It is said to be external when the fluid is in the 
meshes of the pia mater, and internal, when the fluid is in the 
ventricles. 



243 DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 

SYMPTOMS. 

First Variety. 

The head is not much increased in size, but is of a peculiar 
shape. 

The child is often weak-minded — as it has a very small amount 
of brain. 

Second Variety. 

The head increases in size. 
Eyes — sunken. 

Fontanelles — protruding; fluctuation may occur between the 

anterior and posterior f ontaneUes. 
The child is precocious for the first year or two, when nervous 

symptoms appear, and death usually occurs about the age 

of four or five years. 
Third Variety. 

Gradual growth of the cranium out of proportion to the face. 
Gait — unsteady. 

Paralysis — in some cases (from inter-cerebral pressure). 
Involuntary evacuations. 

Child may reach adult life, but it is always a misery and 
trouble to every one. 

TREATMENT. 

Tapping, bandaging, counter-irritation, and various other 
methods have been tried, but all have amounted to nothing. 

CEREBRO-SPINAL MEN"INGITIS. 
SYNONYM. 

*' Spotted fever." 

DEFINITION. 

Is an infectious disease, characterized by an inflammation of 
the meninges of the brain and spinal cord. It may be of an epi- 
demic or sporadic type. 

MORBID ANATOMY. 

On opening the skull, there will be seen a green exudation on 



CEREBRO-SPINAL MENINGITIS. 



243 



the surface of the brain, which is most marked at the base, and 
which extends down the cord. The sulci will be found to be 
deficient and the convolutions sharpened. The dura mater will 
be tense and covered with hemorrhagic deposits. There is an exu- 
dation extending into the meshes of the pia mater of the brain 
and spinal cord, which may be fibrinous, sero-fibrinous, or sero- 
purulent in character, and is very plentiful in the region of the 
optic chiasm, fissure of Sylvius, base of the cerebellum, and the 
fissures of the cerebrum embedding the nerves. 

ETIOLOGY. 

The attacks are more frequent in the winter than in summer, 
as the disease disappears as the summer come^ on. It occurs 
most frequently in children (from 12 to 20) and middle life, and is 
extremely rare in the aged. Bad hygienic surroundings are great 
predisposing and exciting causes to this disease, especially of the 
epidemic form. 

SYMPTOMS. 

Chill or rigors. 

Pain — in all the bones. 

Headache — which is severe and increases. 

Photophobia. 

Pupils — contracted. 

Jactitations. 

Nausea — and perhaps vomiting. 

Pulse— 80 to 100, hard, wiry, and increasing — later on may be 

slower than normal. 
Temperature — moderate. 

Respirations— 30 to 40 a minute and increasing. 
Countenance — pale and anxious (associated with knitting of the 
brows). 

Eruption — appears early on the mouth, cheeks, eyelids, ears, and 
occasionally on the extremities (but that depends upon the 
severity of the case). Is usually herpetic in character^ 

Delirium — slight. 

Pain— in the back of the head and along the spine. 
Muscles of the neck — are rigid. 



244 DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 



Opisthotonos — may occur. 

Thighs may be flexed on the trunk and the leg on the thigh. 
Arm is drawn across the chest, fore-arm is flexed on the arm^ 

and the fingers are clinched. 
Abdomen — is first swollen and then shrunken. 
Great sensitiveness of the skin. 

Deafness — (may occur) — from inflammation of auditory nerve. 
Blindness — may occur from keratitis. 

Coma — may occur (when the following symptoms wiU be noticed): 
Pupils — unequally dilated. 
Eespiration — sighing. 

Urine — is passed involuntarily, or may have to be drawn off* 
Constipation or involuntary evacuations — may occur. 
Capillary circulation is imperfect. 

Patient is aroused with difficulty, and may possibly take food* 
Eruption — may appear only in this stage. 
Emaciation— is rapid. 

CAUSES OF DEATH. 
Death may occur from acute oedema of the lungs, bronchitis, 
or pneumonia. Any of these may occur on the first or second 
day, but usually about the fourth or fifth day. In some cases, 
death appears in a few hours after the symptoms have set in, 
from paralysis or marasmus. 

COMPLICATIONS. 

1. Croupous pneumonia — with no rational complications. 

2. Croupous nephritis— from the cerebro-spinal axis affecting 
the parenchyma of the kidney. 

3. CEdema and congestion of the lungs — due to paralysis of the 
muscles of the chest. 

SEQUELS. 

1. Impairment or loss of hearing and speech. 

2. Impairment or loss of sight — due to inflammation of the 
retina, or from corneal ulcer. 

3. Chronic hydrocephalus (especially in children). 

4. Paralysis and great emaciation. 



EPILEPSY. 



245 



5. Neuralgic pains — about the head in the region of the cranial 
nerves. 

DIFFERENTIAL DIAGNOSIS. 

It may be confounded with other forms of meningitis; with 
pneumonia in children. Sporadic cerebro-spinal meningitis may 
be mistaken for tubercular meningitis. 

The sporadic form is ushered in by a chill and rapid pulse, 
whereas, in tubercular meningitis, there is no chill, and the pulse 
is slow at the beginning. 

PROGNOSIS. 

Is uncertain. The character of the epidemic must be taken 
into account. 

In severe cases, the prognosis is bad. In mild cases, recovery is 
possible. 

TREATMENT. 

It is the custom among the Germans to apply ice-bags to the 
head and spine, while others prefer hot applications. Quinine is 
of Httle or no use; it will not even lower the temperature. The 
patient should be kept in a large, quiet room. The best and 
largest quantity of the most nutritious concentrated diet must 
be given. The temperature should be reduced by sponging the 
surface; and the only remedy that can be employed is opium 
(atropine, gr. -^-q, and morphine, gr. ^) hypodermically ; the patient 
must be kept thoroughly under its influence until death or recov- 
ery ensue. 

EPILEPSY. 
SYNONYMS. 

Falling sickness; morbus sacer; haut or grand mat; and petit 
maJ, 

DEFINITION. 

Is a chronic disease, characterized by a complete loss of con- 
sciousness and sensibility, accompanied, in the severe type, by a 
3udden falling, and distortion of the countenance, and convul- 



246 



DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 



sions. Petit mal is characterized by incompleteness of the above 
symptoms, viz.: no convulsions, only twitcLings; it is also termed 
epileptic vertigo. 

MORBID ANATOMY. 
Often shows asymmetry, such as imperfect development of the 
skull; diffuse thickening or exostoses; the dura mater may be 
thickened, adherent, and calcified; tumors, or deposits in the 
brain ; chronic hydrocephalus ; cerebral hypertrophy ; changes in 
structure of the spinal cord and medulla ; sometimes alterations 
in the substance of the brain; scars, etc. 

ETIOLOGY. 

Excitement of the motor nerves, proceeding from the medulla 
oblongata and the portion of the brain lying upon the base of the 
skull; from dilatation of the arterioles and capillaries of the 
medulla, with thickenings of their walls, producing irritation; 
from cutting off the blood supply (anaemia), or causing afflux of 
arterial blood to the medulla; tumors pressing on the peripheral 
nerves; cerebral tumors and other cerebral diseases; a morbid 
state of the medulla; venous engorgement and over-cliarging of 
carbon dioxide, from, spasmodic closure of the glottis; from in- 
sanity, intemperance, cachexia, onanism, mental emotion, vio- 
lent fright, wounds, syphilis, worms in the intestines, etc. ; or, it 
may be hereditary, often affecting several generations. 

It occurs particularly in females, from infancy up to thirty 
years of age. 

SYMPTOMS. 

Are usually ushered in by 

Aura epileptica —may appear as a sense of vapor arising from 

the extremities toward the head; or like a creeping, 

warm, or numb sensation ; or like a darting pain in the 

brain; or like peculiar odors. 
Aura motor — resembles twitchings or palsy. 
Aura mental — like hallucinations; sparks or colors appearing 

before the eyes; or tinnitus aurium; or dizziness. 
Patient utters a shrill cry. 
Loss of consciousness and sensation. 



EPILEPSY. 



247 



Convulsions. 

Tonic contractions — the patient may fall backward, sideways, 

or forward. 
Head — is drawn to one side. 
Mouth — is firmly closed. 
Face — cyanosed. 

Eyes— wide open, rolled upward or inward. 
Pupils — dilated. 
Thorax — fixed. 

Respiratory movements — arrested. 

Jugulars — distended. 

Clonic spasms and convulsions. 

Grating of the teeth. 

Tongue — is bitten. 

Foaming at the mouth. 

Blood mixed with the foam (from biting of the tongue) ap- 
pears at the mouth. 
Thumbs— turned in on the palms of the hands. 
Head — jerked from side to side. 
Heart's action — accelerated. 
Pulse— small and irregular. 
Skin — bathed in perspiration. 

Involuntary evacuation of the bladder and rectum. 
Involuntary erections and seminal emissions. 

PROGNOSIS. 

Depends upon the cause. Some cases recover perfectly, while 
others withstand all remedial measures. The epilepsy of infants 
and young children gives a better prospect of recovery than when 
developed late in life. 

TREATMENT. 

No epileptic mother should ever be permitted to nurse her child; 
a vigorous wet-nurse should be obtained, and their home should 
be in the country. Regulate the system and surroundings. For- 
bid mental occupation of any kind. The only condition of suc- 
cess is patience, both on the part of the physician and on that of 
the patient. It is necessary to be very stem as regards excessive 



248 



DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 



sexual intercourse, onanism, drink, etc. If anaemia occur, nour- 
ishing diet, wine, iron, and moderate exercise in the open air, 
are indicated. If it occur from scars, foreign bodies, etc. , etc. , 
they must be removed. The following methods of treatment 
have been suggested, with more or less beneficial results, viz.: 
setons, moxa, pustulating ointments, cupping, blisters, etc. ; four 
leeches applied to the back of the neck at a time, every fortnight 
or three weeks; or B atropine, gr. ij.; sp. vini rect., 3 iiss : com- 
mence with gtt. i. every two or three hours, and increase till gtt. 
XX. are given at a dose; or, gtt. v. nitrite of amyl pearls; these are 
crushed on the handkerchief just as an attack is coming on, and 
the patient made to inhale it. 

Bromide of potash, in large doses, or bromide of sodium (this 
latter is three times as strong as br. potash). 

Preparations of oxide of zinc or arsenic. 

When it is complicated with syphilis, iodide of potash or iodide 
of lime will be found serviceable. Iodide of lime comes in 
whitish-yellow cakes, and must be kept from the light, because it 
deliquesces and becomes brown, on account of the iodine. 



OEEEBRAL SOFTEOTNG. 
STARIETIES. 

(1) White or non-inflammatory. (2) Red or inflammatory. (3) 
Yellow. 

DEFINITION. 

Is a disease characterized, during life, by impairment of the 
mind, sensibility or mobility, and after death by softening and 
degeneration of the cerebral substance. 

MORBID ANATOMY. 
The cerebral substance is a moist, gelatinous, trembling pulp, 
which may be of a white or grayish-white color, or, possibly, red 
or yellow. The yellowish color is said to depend on capillary 
hemorrhage or fatty degeneration (is due to infiltration of the 



MYELITIS. 



249 



disintegrated brain-substance with escaped and altered coloring- 
matter of the blood, or to a close aggregation of fatty matter). 

ETIOLOGY. 

Is due to necrosis (resulting from obstruction of the vessels and 
insufficient development of the collateral circulation, or to local 
inflammatory changes); occurs generally in the greater hemi- 
spheres, chiefly in the medullary substance. It may follow a 
rupture of the cerebral arteries; this latter occurs chiefly in the 
aged and decrepit, from disease of the vascular walls, which 
generally induces thrombosis. 

SYMPTOMS. 

Peripheral arteries — rigid, turgid, and contracted (in the old). 
Large arteries— dilated (if atheroma exist in the vessels). 
Impairment of mind, sensibility, and mobility. 
Paralysis — which may precede or follow the mental impairment). 

PROGNOSIS. 

Is unfavorable, unless dependent upon some local cause which 
can be overcome. 

TREATMENT. 
Same as in anaemia of the brain, (page 228). 

MYELITIS. 
DEFINITION. 

It is a red softening of the spinal cord, in circumcribed spots ^ 
which becomes yellow, after a lapse of time, from fatty degener- 
ation of the broken-down nerve-elements; it may produce abscess 
of the spinal cord. It may be either acute or chronic. 

MORBID ANATOMY. 
A cavity may be formed in the spinal medulla filled with serum, 
and traversed by connective-tissue: or there may be an induration 
from connective-tissue proliferation. On section — the gray sub- 



250 



DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 



stance of the cord is darker, redder, and less consistent than nor- 
mal. The medulla is swollen, and in its centre is a reddish, rusty, 
or yellow pulp. The tissues are broken down and often absorbed, 
so that there may be a cavity filled with serum. 

ETIOLOGY. 

Inflammation extending from the vertebra to the membranes 
and thence to the medulla; curvature of the spine; wounds; con- 
tusions; syphilitic exostoses; cold; sexual excesses; excessive 
straining; dissolute habits; suppression of perspiration of the feet; 
masturbation. 

SYMPTOMS. 

Severe fever— at the onset. 

Extensive pain in the back and extremities. 

Tetanic spasms of the neck. 

Clonic spasms of the extremities. 

Dyspnoea — (if the disease be situated very high up). 

Paraplegia and anaesthesia (partial). 

Numbness and irritation. 

Vague pains. 

Sensation of pricking. 

Formication. 

Painful contraction of the extremities. 

Spasmodic twitchings — due to irritation from inflammation of 
the motor nerves. 

Pain — like a cord tied round the imist—diMW at the point of in- 
flammation. This pain is increased by pressure on the spinous 
processes and not by the movement of the spinal cord. 

Paralysis — becomes complete; the bladder and rectum are para- 
lyzed, and atrophy of the paralyzed muscles takes place — 
heaviness and helplessness of the lower extremities. 

Urine— will be alkaline. Digestive powers— are good, unless the 
disease is high up in the spinal cord. 

If cervical region be affected — then the upper extremities and 
and respiratory muscles are involved. 

If the dorsal region be affected — then the sphincters may be in- 
volved. 



LOCOMOTOR ATAXIA. 



251 



If the lumbar region he affected — then the lower extremities are 
involved. 

SYNOPSIS OF SYMPTOMS. 
Gradual paralysis — extending upward. 

Pain — in the back on pressure, (not increased on motion of spine). 
Sense of heat on the affected portion, whether heat or cold be ap- 
plied. 

Sensation as if a tight cord were tied round the body, correspond- 
ing to the seat of disease. 
Overflow of urine— from paralysis of the bladder. 

CAUSES OF DEATH. 
Death may occur from bed-sores, cystitis (from stagnation of 
urine due to paralysis); tuberculosis, or some intercurrent disease; 
pyelitis; ammonaemia. 

PROGNOSIS. 

May run on for years and then remain stationary. Recovery is 
rare. Gradual advance to death from complications. 

TREATMENT. 

Is of very little service. The actual cautery and hot iron should 
be applied near the supposed seat of inflammation. A sponge 
dipped in hot water may be placed along the spine, especially 
where the inflammation is most severe, with some benefit. 

LOCOMOTOR ATAXIA. 
SYNONYMS. 

"Tabes dorsuaUs," — or gray degeneration, or softening of the 
posterior columns of the cord. 

DEFINITION. 

Is a disease characterized during life by imperfect co-ordination 
of muscular movement and sensory manifestations; and after death 
by disease of the posterior columns of the cord. 



353 



DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 



MORBID ANATOMY. 

The disease is confined to the posterior columns of the cord; the 
dura mater is thickened and opaque. The arachnoid is moder- 
ately opaque, and there is fluid in the sub-arachnoidean space. 

The pia mater is thickened, opaque, and adherent over the 
affected part. The posterior columns are degenerated, the degen- 
erated portion is wedge-shaped, with its apex directed toward the 
centre of the cord. It appears as a reddish, soft mass. The 
posterior roots of the spinal nerves are degenerated and the antero- 
posterior diameter of the cord may be shortened, due to degener- 
ation and possibly sclerosis. 

The microscope shows few nerve filaments in various stages of 
atrophy, and, between the cells, nucleated connective-tissue from 
proliferation. 

ETIOLOGY. 

It may follow exposure to dampness, as in the case of fisher- 
men; abuse of alcohol; syphilis; masturbation; excess of venery; 
severe muscular strain, as in long marches, etc. 

SYMPTOMS. 

Premo7iitory symptoms. 

Tearing localized pains in the lower half of the trunk which 

are more or less paroxysmal (may last for a long time, 

even for years, before ataxia occur). 
Delayed sensation and absence of ''patellar reflex.''^ 
Sense of formication in the lower limbs. 
Sense of numbness in the lower limbs. 
Sensation as if a ligature were tied around the body. 
If the disease be high up. 

The upper extremities may be affected as well as the lower, 

although the lower limbs are chiefly involved. 
Sense of insecurity in walking — especially when any sudden 

movement is required, as in crossing a street. 
Abnormal sensation in walking — as if walking on air or wool. 
No dragging of the limbs exists — but the limbs are forcibly 

lifted and thrown in the wrong direction. 
TJie patient is liable to fall if the eyes be closed — or if Avalking 

in the dark (this must not be considered pathognomonic 

of this disease). 



LOCOMOTOR ATAXIA. 



253 



No motor paralysis, or atrophy in any special muscles — as you 
can move and put the limb in any position and retain it 
there in spite of a counter-extending force. 

Sexual intercourse is often decreased, but priapism may be 
present. 
In the advanced stage. 

Walking — is almost impossible ; the feet are swung in a circle, 
the heel striking the ground first, and then the sole of the 
foot ; the gait is jerky in character ; the patient may fall 
from inability of co-ordination of the muscles, and often 
, loses his equilibrium. 

If the upper part of the cord be affected, the patient cannot 
button his coat or collar, neither can he carry a glass of 
water steadily to his mouth (since co-ordination of move- 
ment is demanded) and the handwriting is markedly 
affected. 

Paralysis of the sphincter vesicae (incomplete enuresis, due to 
too long retention). 



Diploplia I 

Strabismus \ from paralysis of the third and sixth nerves. 
Ptosis 



Pupil fails to respond to light, hut alters its size in efforts of 

accommodation of vision. 
Cerebral disturbances. 

CAUSES OF DEATH. 

Death may occur from bed-sores (from enuresis); severe cysti- 
tis; pulmonary consumption; and intercurrent diseases. 



If there be a suspicion of syphilis, use the anti-syphilitic reme- 
dies. If from having taken cold, leeches and blisters should be 
applied along the spine; sweating in moist clothes may be of 
benefit; and the continuous current along the spine and the course 



PROGNOSIS. 



Recovery is extremely rare. 



TREATMENT. 



254 DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 

of the spinal nerves may possibly prevent the extension of the 
disease. 



PKOaRESSIVE MUSCULAR ATROPHY. 
MORBID ANATOMY. 

The muscles are decreased in size, pale, and yellow, with bun- 
dles of atrophied and degenerated tissue; and in the later stages, 
degeneration of the whole muscles. 

The microscope shows paleness of the muscular fibrillee; no 
transverse stpse, fine granular fat-globules in the centre of the 
fibrillae; later on, collapse of the sarcolemma and fat-globules in- 
closed. The muscles of the heart, intestines, or bladder are never 
affected. It affects principally the muscles of the hand, hip, or 
shoulder. It may affect one muscle, or group of muscles. 

ETIOLOGY. 

It is a primary disease of the muscles, and degeneration of the 
anterior roots of the spinal nerves, due to disease of some small 
part of the brain, or spinal marrow, and over- work of the muscles. 
It attacks all ages and both sexes. 

SYMPTOMS. 

Increased feeling of weakness in certain muscles or group of mus- 
cles. 

Rapid disappearance of muscles — commencing in the hand, hip, 
or shoulder, causing alteration in the ball of the thumb, flat- 
tening of the shoulder, and prominence of the spuious pro- 
cesses of the vertebrae. 

Loss of muscular action of the affected side. 

A peculiar fibrillar twitching (as though the skin were alive) in 
the weak and atrophied muscles, but no movement of the 
joints. 

A loss of sensory muscular nerve power. 

The electric current does not fail to induce contraction until the 
muscle is entirely atropliied (pathognomonic). 



SUNSTROKE. 



255 



The thigh may become even smaller than the calf of the leg when 

the muscles are greatly atrophied. 
Intellect is clear throughout. 
In advanced cases. 

Patient cannot walk or change position. 

Patient requires to be fed. 

Arms hang loosely to the sides of the body. 

Loss of expression of the countenance ) evidences of exten- 

Saaiva flows from the mouth } eh"„Tward. 

Speech is indistinct (due to extension of disease to medulla). 

Tongue cannot pass the food into the pharynx, even after it 
is placed in the mouth. 

CAUSES OF DEATH. 
Death may occur from atrophy of the muscles of respiration, 
and deglutition, causing failure in the performance of their func- 
tion. 

TREATMENT. 

The induced or constant current should be frequently apphed 
with great patience and perseverance. 



SUNSTROKE. 
SYNONYMS. 

Coup de soleil ; Calenture ; Insolation ; Sun fever ; Heat apo- 
plexy ; CEgyptian starstroke ; Heatstroke ; Thermic or heat fever. 

DEFINITION. 

Is a disease characterized by a more or less sudden attack of 
unconsciousness due to exposure to high temperature under ad- 
verse circumstances. 

MORBID ANATOMY. 

In most cases of fatal sunstroke the blood is found to have re- 
mained uncoagulated ; the lungs intensely congested ; the right 
side of the heart loaded with blood ; and generally more or less 



256 



DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 



engorgement of the vessels of tlie brain. The body also loses its 
heat very slowly after death. Some observers assert that a slight 
increase usually takes place. 

ETIOLOGY. 

Exposure to an intense heat where the atmosphere is damp and 
impure, and the patient exhausted by over-exertion or from any 
means which impede the free action of the respiratory muscles. 
In tropical climates it frequently occurs from exposure to the 
direct sun rays and want of acchmatization. It is also very com- 
mon at night-time among those subjected to close, over-crowded, 
ill-ventilated barracks, tenement houses, ships, etc ; soldiers ex- 
posed to long marches in the heat of the day. Intemperate and 
debilitated persons and those who drink largely of iced-cold water 
when greatly exhausted are very hable to be affected. 

SYMPTOMS. 

Onset may be sudden but frequently preceded by premonitory- 
symptoms. 

When onset is sudden. 

Patient falls unconscious. 
Head — intensely hot. 
Skin — pale, cold and moist. 

Eespiration — gasping and is apt to be stertorous. 
Ptdse — extremely feeble and rapid. 
Temporal arteries — greatly distended. 
Temperature internal — above normal. 

Convulsion may precede death which takes place very rapidly 
or even quite suddenly^ 
Wlien onset is gradual. 

General malaise— which may be present for several days. 

Skin — dry and hot. 

Nausea. 

Frequent desire to micturate. 
Restlessness or insomnia. 
Face — flushed. 

Eyes — congested. - 
Constipation. 



SUNSTROKE. 



257 



Vertigo. 

Headache — intense. 
Vision becomes dim. 

Weakness in the limbs and great prostration. 
Coma — which may be partial or complete, when 

Breathing — stertorous. 

Pupils — contracted. 

Face — pallid. 

Skin — intensely hot. 

Temperature — varies from 100 to even 109°. 

Pulse — rapid and full and as death approaches becomes 

weak, irregular but very rapid. 
Convulsions — sometimes. 
Bowels— relaxed. 
Vomiting — not infrequent. 

SEGUELCE. 

Headache ; chorea-like affections of the muscles ; epilepsy ; and 
jome degree of mental imbecility ; amaurosis. 

DIFFERENTIAL DIAGNOSIS. 
From apoplexy ; delirium tremens ; insaniiy ; eclamj)sia ; par- 
alysis. 

PROGNOSIS. 

Is unfavorable, the mortality being very heavy, exceeding, it is 
said, forty per cent. 

TREATMENT, 

Depletion should never be resorted to. The patient should be 
placed in a cool room ; his clothes removed and a cold shower hath 
administered. The shower being at least from four to five feet 
above the i^atients head. When removed from the bath the head 
should be shaven and cold applied to the head. If there be 
dyspnoea dry cups placed on the thorax in front and behind will 
be of service. Bromide of potassiu m gr. v.-xxx. should be given 
in all stages of the affection and in mild cases (gr. v.-x.) may be 
administered every half an hour to an hour until the grave symp- 
toms disappear ; if the patient be unable to swallow it can be 



258 



DISEASES OP THE BRAIN AND NERVOUS SYSTEM. 



given by injection remembering that the dose should always be 
increased one quarter more than when administered by the mouth. 
Stimulants such as brandy and milk, or brandy and ammonia, 
should be given whenever exhaustion is prominent and the cold 
douche dispensed with whenever the skin is cold. After retm*n of 
consciousness, blisters or sinapisms should be applied to the back 
of the neck or behind the ears. The bromide should be continued 
for at least two weeks after the return to consciousness. When 
convenient, the patient should be sent to a cool district and free 
from all excitement or mental or physical exertion. Regular 
habits and exercise should be enforced. In order to prevent or 
lessen the danger from nervous affections which are apt to follow 
sunstroke, a continuance of this treatment for some months 
should be adliered to. 



COMA— ITS PEINCIPAL CAUSES AND DIFFEE- 
ENTIAL DIAGNOSIS. 

The most frequent causes of coma, (see page 26), comprise, syn- 
cope, cerebral concussion and compression, asphyxia, epilepsy, 
apoplexy, emboUsm, hysteria, catalepsy, uraemia, alcohol, and 
opium. 

Syncope. 

Pulse, teeble; face, pale; respiration, quiet; duration, short. 
Cerebral Concussion. 

Pulse, rapid and feeble, and intermittent; skin, pale and cold; 
respiration, feeble and sighing; pupils, usually contracted; coma, 
incomplete, is usually immediate, and rapidly decreases, as a rule; 
temperature, lowered; eyelids, usually open and movable; vomit- 
ing, frequently present; incontinence of urine and involuntary 
evacuations occur; duration, short. 

Cerebral Compression. 

Pulse, full and slow; skin, usually warm and moist: respiration, 
slow and stertorous; pupils, may be natural, dilated, or irregular; 



COMA. 



259 



coma, profound, may not directly follow the injury, and is station- 
ary or increasing; temperature, normal or increased; eyelids, 
closed and immovable; vomiting, rare; retention of urine and 
obstinate constipation ; paralysis (modified by seat of lesion). 

Asphyxia. 

Face, livid ; lips, blue ; extremeties, blue and cold ; respiration, 
distressed. 

Epilepsy. 

Epileptic cry on onset; tongue, ragged; history of previous 
attacks ; pupils, dilated ; mouth, bloody froth exudes ; spasms, 
tonic and clonic ; body, one side more convulsed than the other , 
reflex sensibility present ; duration, short, and followed by a deep 
sleep ; loss of consciousness of short duration. 

Apoplexy. 

Coma, may occur at onset or develop rapidly, and deepens; 
hemiplegia; pulse, slow and full; face, flushed; pupils, irregular; 
respiration, stertorous; condition of arteries, usually atheroma of 
those which are superficial; age, usually occurs at about 50 years; 
history, high living, etc. ; muscles, rigidity or relaxation. 
Embolism. 

Advent, is sudden, with consciousness; paralysis, usually of the 
right side; improvement, is usually marked within twenty-four 
hours (due to collateral circulation); face, pale or normal; respira- 
tion, sighing; aphasia, usually present either of the amnesic or 
ataxic variety; age, may occur at any time; pupils, dilated or 
irregular; history, may be rheumatic, or evidence of mitral or 
aortic disease may be detected on auscultation. 

Hysteria. 

Globus hystericus; large amount of pale urine in the bladder, 
which is passed after the attack; a previous history of attacks of 
hysteria; most common in females. 

Catalepsy. 

Limbs, at first rigid, then become loose and will remain in any 
position in which they may be placed. 



260 



DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 



Ur-^mia. 

Is of gradual onset; face, pale and waxy; pupils, dilated; eyes, 
closed; coma, complete; oedema, of face and limbs; ursemic odor 
of the body, and especially of the breath; urine, contains casts 
and albumen; history of convulsions. 

Alcohol. 

Pulse, rapid; face, flushed; skin, warm and moist; respiration, 
stertorous and puffy; pupils, dilated, and respond to light; no 
paralysis; breath, alcoholic; vomiting, occasional; eyes, injected; 
temperature, below normal; feet, are drawn back when tickled; 
history of drinking. 

Opium. 

Onset is gradual; face, dusky ; skiii, moist ; pulse, slow and full; 
pupils contracted, (xjinhole); respiration, slow and irregular, and 
there may be an interval between expiration and inspiration ; 
patient can be roused till coma deepens ; vomiting (the matters 
vomited have the odor of opium) ; breath, has the odor of opium ; 
the attack tends to deepen, the respiration gradually becoming 
slower and slower as the drug exerts its influence. Tlie patient, 
when roused, answers questions rationally, in marked contrast to 
some other forms of coma (especially alcoholism). 



DISEASES OF THE BLOOD. 



ETIOLOGICAL DIVISION OF FEVERS. 



1. Miasmatic contagious. 

The poison must be deposited in decomposing organic matter 
exterior to the body, so that, when once in a body or system, 
whose condition is impaired or weakened, the poison is re- 
produced. It can only be conveyed through the excrements 
of the sick, or through decomposing organic matter exterior 
to the body, with which such excrements have come in con- 
tact. They may be endemic or sporadic (as in typhoid and 
yellow fever). 

2. Malarial or miasmatic non-contagious. 

Where the morbific agent is developed exterior to the body 
(as in simple intermittent, simple remittent, pernicious, 
dengue, and typho-malarial fevers). 

3. Contagious. 

Where the morbific agent is developed in the body, and can 
be transferred through the atmosphere to another (as in ty- 
phus, measles, small-pox, relapsing, scarlet, and miUary 
fevers. 

TYPHOID FEVER. 
DEFINITION. 
Is one of the miasmatic-contagious fevers. 

SYNONYMS. 

Autumnal, abdominal-typhus, enteric, gastric, gastrO-enteric, 
forty day, dothenenteria, ilio-typhus, typhoid affection of Louis. 

MORBID ANATOMY. 
There is the change in the blood which becomes darker in color, 
imperfectly coagulable, and the serum is of an unnaturally yellow 
color. Through these blood changes, the various tissues and 



262 



DISEASES OF THE BLOOD. 



organs in which the process of repair and waste are carried on 
become affected, as the spleen, liver, kidneys, heart, lungs, bron- 
chial tubes, larynx, brain, stomach, muscles, and salivary glands. 

Spleen. — Is sometimes eyiormously increased in size (for about 
three weeks), becoming soft, of a dark jelly-like mass, easily 
broken down (from congestion); or there may be infarctions and 
rupture, but if recovery take place, the spleen will return to its 
normal size. 

Liver. — May be normal, or soft and flabby, with more or less 
granular, fatty, and lymphoid cells; or there may be catarrhal or 
diphtheritic inflammation, or ulceration of the lining membrane 
of the gall-bladder. 

Kidneys. — Degeneration may take place, especially in the epi- 
thelial elements of the cortical substance, but not so markedly as 
in typhus. 

Heart. — Parenchymatous changes are more marked than in any 
other organ (from faulty nutrition); becomes soft and flabby, and 
of grayish or brown color; is easily broken down, and the walls 
of its cavities readily fall together (on account of granular degen- 
eration); its muscular fibres have an amyloid appearance, which 
does not answer to the iodine test (this change also takes place in 
the voluntary muscles of the body). There may be thrombi in 
the heart, or vegetations on the valves, or chordao tendinese, pro- 
ducing infarctions and feeble heart-sounds, and the first sound 
may be entirely absent. 

Lungs. — Undergo splenization; they may be of a dark reddish* 
blue, black, or brown color, harder and drier than normal, and 
when cut, a dark watery fluid oozes out (due to stasis in the 
capillary circulation). 

Death may ensue from pulmonary infarctions. These infarc- 
tions in the recent state are dark and feel like consolidated lung- 
tissue, but later may change to a yellow color, or may soften and 
break down. 

Bronchial tubes. — There is extensive catarrhal inflammation of 
the larger tubes, generally giving rise to capillary bronchitis or 
broncho-pneumonia. 

Larynx. — There may be extensive catarrhal inflammation. 



TYPHOID FEVER. 



36a 



Ulcers (called typhoid ulcers) may occur, causing extensive 
hemorrhage (this type of ulceration may affect the mouth and 
pharynx, or even the epiglottis or mucous membrane of the Eus- 
tachian tube, producing deafness). 

Brain and nervous system. — (Edema of pia mater and brain^ 
substance may exist, with extensive adhesions to dura mater (not 
much, however, is known of these lesions). 

Stomach. — Changes in this organ are sometimes extensive. 
Softening and degeneration of its glandular structure occur, 
which are the causes of disturbances in digestion during the fever 
and even during convalescence. 

Muscles {voluntary), — There may be granular or fatty degenera- 
tion ; or a waxy or amyloid degeneration. The muscular fibres, 
in both instances, become thick and friable, and are yellowish- 
white in appearance. The want of muscular power of fevers de- 
pends on the nervous disturbance, but the excessive loss of mus- 
cular power in convalescence is due to muscular changes. 

Salivary glands.— These become enlarged, tense, and firm; are 
of brownish-yellow color, and later on they become red (due, first, 
to cellular hyperplasia, and secondly, to degeneration). 

Intestinal lesions are the most important of all the lesions, and 
are characteristic. The poison acts on the mucous membrane of 
the small intestine, producing catarrhal inflammation and 
changes in its structure. These changes are modified by the 
duration of the fever, and their nearness to the ileo-coecal valve. 
They are most marked in the patches nearest the valve (ileo-coecal). 

The intestinal changes in the regular course of a severe case may 
be thus summarized: 

First week. — The mucous membrane around Peyer^s patches 
becomes congested and swollen; the glands become more and more 
elevated; and the surfaces are of a dark-red color, interlaced by 
white lines ("shaven beard appearance"). These changes are 
, most marked nearest the ileo-coecal valve. 

Second week.— The mucous membrane of the intestines becomes 
less red; the solitary glands more elevated; the wiiite lines on 
their surface disappear; and are uniformly red. There is an ex- 
cessive cell growth in the follicles (due to rapid development of 



264 



DISEASES OF THE BLOOD. 



lymphoid cells, principally within their structure, causing pressure 
on the capillaries and interfering with the circulation of gland- 
tissue). Toward the end of the second week, degenerative changes 
are established in the new tissue, which may become disinte- 
grated, absorbed, and undergo resolution; or the follicles may rup- 
ture into the intestines, or more frequently the dead tissues slough 
and ulcers are formed. 

Third week. — These ulcers are yellowish on account of staining 
by bile. When sloughing takes place, the entire gland and mucous 
membrane surrounding it are removed and the muscular coat laid 
bare. The edges of the ulcers are sharp, swollen, and overhang 
the floor of the ulcers, and may terminate in perforation of serous 
coat and fatal peritonitis. These ulcers may be hemorrhagic, 
and destroy life in this manner. 

Fourth week. — Cicatrization commences. The swollen edges 
subside. Granulations spring up from the base of the ulcer (which 
is the muscular coat of the intestine); connective-tissue is formed; 
edges unite at their base, and are covered with a layer of epithe- 
lium. The cicatrix is depressed, becoming more and more pig- 
mented, but seldom causes any puckering or diminution in the 
calibre of the intestines. Death may result from prolonged ulcer- 
ation. 

Mesenteric glands. — Those nearest the ileo-coecal valve are 
affected secondarily to the intestinal glands. They are first Con- 
gested, then lymphoid and large cells are produced, causing en- 
largement and acute cellular hyperplasia; and, about the end of 
the second week, the glands become disintegrated. Tliey are often 
about the size of a walnut or hen's egg. Some of the glands 
shrink to their normal size, others soften and are absorbed, and 
leave a fibrous cicatrix. When of very large size, absorption may 
be incomplete, and a dry, yellow cheesy mass is left; salts of lime 
are often deposited in them, and they become inclosed in a fibrous 
capsule; or they may become fluid, their capsules destroyed, enter 
the peritoneal cavity, and produce peritonitis. 

Suppurative inflammation in the cellular-tissue, on the surface 
of the body, may be another lesion occurring during convales- 
cence, accompanied by redness and pain. A tumor of a fluctu- 



TYPHOID FEVER. 



265 



ating nature is formed wherever there is the greatest pressure, or 
two or more of them may coalesce. 

Bed-sores (in later stages) occur from imperfect skin nutrition 
and prolonged high temperature. They are most frequent over 
the trochanters or sacrum, or wherever there is pressure, and may 
involve the muscular structures. 

Gangrene of the toes may occur, due to thrombosis or embolus, 
from pressure on circulation of lower extremity. 

SYNOPSIS OF THE PATHOLOGICAL CHANGES. 

The pathognomonic lesion is confined to Peyer's patches and 
mesenteric glands. In these, the following changes occur: 

1st. Congestion ot Peyer's patches (producing " shaven beard " 
appearance). 

2d. Hyperplasia and hardening of these glands. 

3d. Softening of glands from fatty degeneration. 

4th. Absorption or rupture, with evacuation of contents. In 
case of rupture, an ulcer is left, whose long axis is parallel to the 
length of the intestine; the edges are ragged and undermined, 
and the floor is formed by the muscular wall of the intestine. 
The ulcers are on the unattached border of the intestine. 

5th. Cicatrization of these ulcers, and a pigmented cicatrix. 
In severe cases, perforation at the seat of ulceration may occur. 
The mesenteric glands undergo enlargement, and softening 
through fatty degeneration. 

All of the organs are generally softened and fatty, and the 
muscles are in a state of fatty degeneration. There is extreme 
emaciation, and the common lesions of all fevers exist (see page 
316). 

ETIOLOGY. 

The poison, which is contained in the feecal discharges of the 
sick, if fresh, undergoes development outside the body, especially 
in soil saturated with organic matter, and gains access to the sys- 
tem by the air we breathe and the water we drink. The period 
of incubation is from fourteen to twenty-one days. It is more 
frequent in the autumn than any other time of the year. It oc- 



266 



DISEASES OF THE BLOOD. 



curs more frequently between the ages of 15 to 25. Exposure, 
bad nutrition, and debility of system favor its development. 

SYMPTOMS. 

Early symptoms of geyieral malaise. 
Vomiting of greenish fluid. 
Headache (lasts from seventh to twelfth day). 
Intolerance to light. 
Pains in limbs (all over the body). 
Chills and fever, but not well marked. 

Slight diarrhoea. ^ 
Variations in temperature. 

Temperature — 

First week. — Gradual and steady rise morning and evening. 
In mild cases 103°. In severe cases 105° to 106°. High Id 
morning (from 12 to 6 p.m.). Low in evening (from 6 P.M. 
to 8 A.M.). Pulse 98 to 110, and increases about five beats 
for every degree of temperature. 

Second Week. — Temparature and pulse remain at their maxi- 
mum till the end of this week when a dechne usually 
occurs ; may be rapid and feeble. Pulse may go to 120 ta 
140. If 140, it denotes feebleness of heart's power, and is* 
a had omen if it remains so for five or six days. 

TMrd 2<7eeA;.— Variations are remittent in character. If pulse 
and temperature keep high, is fatal. Heart-sounds may 
he inaudihle, and prompt attention to the patient is then 
indicated. 

* Fourth iveek. — Variations are intermittent and exacerbations 
" not so severe. 

Eruj)tion— begins from sixth to twelfth day, and remains till the 
fourteenth day; consists of lenticular spots scattered over abdo- 

^ men and chest, are of a hrigh t rose-color, and disappear on the 
slightest pressure and retur n directly. Each spot remains three 
days and then disappears, ivhen another hatch takes its place. 
The latter is the distinguishing point of the eruption, ©a . ^ 
Costa says it resembles flea bites. , - * • 

Delirium — low muttering, and often becomes maniacal at niglit. 



TYPHOID FEVER. 



267 



Diarrhoea — if slight throughout, is not a bad sign, but excessive 
diarrhoea is an unfavorable symptom. Generally commences 
about second week, is alkaline, and of a yellow-green color 
{pea soup). 

Stupor. — This is a common symptom. 

Great emaciation is marked, if the disease be typical. 

Subsultus or twitchings of the wrists, picking at the bedclothes, 
may be present. 

Involuntary evacuations and micturition. 

Tongue — is at first of a light white color, then red on the tip and 
sides, and dry in the centre; then heavily coated, with sordes 
on teeth and sides of the mouth. May become clean and 
shining like raw beef, or the tongue and lips may be dry 
and cracked, and the mouth covered with dark incrustations. 
Hemorrhage from the gums may also occur. 

Countenance - pale, olive, or leaden look. Eyes dull and pupils 
dilated. Conjunctiva congested, hectic flush, and a sunken 
and anxious expression. 

Tympanites— (from gas in the intestines, due to changes in mucous 
membrane), indicates danger, if excessive. 

Pain and tenderness in right iliac fossa — about the sixth day 
(never press with the tips of the fingers lest the intestine he 
ruptured); pain may be due to perforation, when there will 
first be sudden diarrhoea, and aggravated pain on pressure in 
the abdomen; the pain of typhoid may be located, at first, in 
right iliac fossa, but soon extends over entire abdominal cavity. 

Intestinal hemorrhage — from a trace to 16 or 18 ounces, is pre- 
ceded by sudden rise in temperature and extreme fall. If pro- 
fuse, it is due to the opening of an artery with an intestinal 
ulcer, and preceded by fall of temperature, etc. 

Nausea — (later on in the disease). 

Vomiting — (later on in the disease) which may be due to acute 
gastric catarrh or general peritonitis. 

Cyanosis and collapse — (later on in the disease). 

Epistaxis — may occur during the first week and is of little impor- 
tance, but when it occurs during the third week it may be 
so profuse as to destroy the life of the patient. 



268 



DISEASES OF THE BLOOD. 



Somnolence. 

Muscular prostration and, in severe cases, paralysis may develop. 
Aphonia. 

Deafness — due to ulceration of mucous membrane lining the 

Eustachian tube. 
Perverted taste. 
Excessive hypersesthesia. 
Enlarged spleen. 

Urine — is first diminished and then increased. Albumen very rare. 
Lungs — typhoid rale, a sonorous, dry, ringing sound, is often 
present and is due to a bronchial complication. 
If convalescence take place, the edges of the tongue will be 
moist, this moisture extending all over the tongue. 

SYNOPSIS OF THE SYMPTOMS. 

First Week. — Temperature, mild cases, 103°. Severe cases, 105° 
to 106°. Pulse, 98 to 110. Epistaxis; slight diarrhoea; tympanites; 
and tenderness over right iliac fossa and gurgling (bad omen). 

Second Week. — Temperature and pulse may fall to normal, or 
pulse go up to 120 to 140 (about the seventh day). Eruption {from 
sixth to eighth day) generally commences at this time and re- 
mains till the fourteenth day; appears on abdomen and lower part 
of the chest, may be scanty and is of a bright rose colcr, etc. 
Marked diarrhoea (resembling pea soup). Dehrium — low mutter- 
ing, or maniacal. Coma vigil. Subsultus tendinum. Picking of 
the bed-clothes. Symptoms of bronchitis; tongue brown, dark, 
and incrusted; sordes on teeth, etc. 

Third Week. — Epistaxis, or intestinal hemorrhage (alarming), 
and other fatal symptoms. If convalescence take place, the enip- 
tion disappears gradually, as do also the other symptoms. There 
is, in the convalescent stage, danger of perforation for six months. 

DIFFERENTIAL DIAGNOSIS. 
In early stages, with typhus, relapsing, typho-malaria, acute 
tuberculosis, pyaemia, septicaemia, pneumonia, gastro-euteritis, or 
trichonosis. 
Acute Tuberculosis. 

Temperature — 106° or 107°, (and no remissions). 
Spleen — not enlarged. 
No eruption. 



TYPHOID FEVER. 



Typhoid Fever. — Temperature, rarely 106 (with remissions). 

Enlarged spleen. — Eruption, red-rose color. 
In trichonosis. 

No eruption ; pain in the joints (resembling acute articular 
rheumatism); and by taking a piece of the pectoral muscle and 
placing it under the microscope the parasite will be seen, which 
determines the diagnosis. 
In Pycemia and Septicoemia. 

Jaundiced hue to surface; no eruption; early symptoms of 
profuse sweating; emaciation; delirium, etc.; history. 
In Typhoid Pneumonia. 

Typhoid symptoms; coma in later stages; cough and expec- 
toration; no variation in temperature. 
In Gastro-enteritis. 

Diarrhoea and vomiting precede the fever, and the tempera- 
ture is never higher than 103°. 

PROGNOSIS. 

So long as abdominal symptoms last, the patient is not out of 
danger, as changes are still going on. If the temperature be not 
higher than 104° to 105° on the eighth day, and is regular in its 
development — the prognosis is favorable. 

In all cases, the heart is the guide; for, if pulse be 110 to 115, 
and there be a distinct first sound; and, at the end of second week, 
the temperature be even 106°— favorable. If pulse be 120 to 130, 
feeble apex-beat, first sound indistinct or obscure, and tendency 
to cyanosis — be on your guard. 

It is the rise and fall in pulse that denotes the danger. The 
prognosis is always bad, in fat persons and gouty subjects, or if 
complicated by kidney troubles. There is great danger of peri- 
tonitis from ulceration and hemorrhage, if the attack be severe. 
Bad prognosis, in alcoholists and when occuiTing in connection 
with chronic diseases. Bad, in complications, as diminished heart's 
action from muscular degeneration, favoring pulmonary and other 
hypostatic congestions. Bad, in intestinal perforations, capillary 
bronchitis, oedema of the lungs, latent pneumonia, laryngitis (from 
protracted fever and prostration, causing ulceration of mucous 
membrane) pyaemia, acute gastric catarrh. Bad, if brain symp- 
toms occur, as oedema, hemorvlingic extravasations, liemiplegia, 



270 



DISEASES OF THE BLOOD. 



and paraplegia, also in parenchymatous nephritis, severe catarrh 
of bladder, celluKtis, and bed-sores. 

Death may result from toxaemia, asthenia (debility), suppression 
of excretory functions of kidney, hyperaemia, and oedema of the 
lungs, intestinal hemorrhage, exhaustive diarrhoea, intestinal per- 
foration, peritonitis, with or without intestinal perforations; re- 
lapse from reabsorption; and from cathartics, if given during first 
week. 

TREATMENT. 

Always use a porcelain bed-pan, covered over the bottom with 
a layer of powdered sulphate of iron, and, directly after the dis- 
charge, cover it all over with muriatic acid (about equal to one- 
third of the mass). Dig trenches, but not near a privy or drain, 
and empty contents of bed-pan into these trenches. Remove all 
soiled bed-clothes, immerse them in chlorine water, and boil them 
within twenty-four hours. Examine the pipes, wells, etc., etc., 
and see the house sewer-pipes do not leak. Disinfect thoroughly, 
for after the poison has once entered the system there is no pre- 
ventive. 

Arrangements of the sick-room are of the utmost importance. 
An experienced nurse. Large well-ventilated room. Remove all car- 
pets and all superfluous things. Temperature of the room 60°. No 
fruit or solid food. Patient must be kept in bed. Milk, ad libitum. 
In early stage (temperature 103*'), sponge surface with cold or tepid 
water. Keep down temperature with quinine and cold (using 
bath, packs, and affusions). If temperature rise above 103° in 
axilla, then warm bath, 70° to SO'', and gradually lower the tem- 
perature of the bath by ice or water till patient begins to feel the 
effects; probably it will have to go to 60°, but not below this. If 
temperature fall rapidly to 103°, remove patient at once; but, if 
slowly, do not remove patient till temperature of 101° be reached, 
and apply cold to head; this should only be done during first and 
second week. Cold pack shor.ld be thus applied: wring out a 
sheet in tepid water, and one in cold water, and wrap round the 
patient; or apply ice-bags to abdomen. Be very careful when 
using cold applications. 

Quinine, in large doses, 30 to 40 grains ivithin two hours, or 10 



TYPHOID FEVER. 



271 



grains every half -hour for four doses, but do not continue it when 
once temperature is reduced, unless it be 105°, then reduce to 
101°, and keep it there. If, after the third week, you fail to re- 
duce the temperature, add gr. x-xx, pulv. digitalis, unless pulse 
be frequent and irregular, then only use quinine. 

If weakness and failure of heart's power occur during the third 
week, and the temperature be about 101°, pulse 140, with first 
sound inaudible, subsultus, dry tongue, etc. , use stimidants, hut 
he very carefid of the first few doses, and see your patient every 
two hours, so that, if he be restless, delirium more active, temj)er- 
ature higher, pulse more and more rapid, stop it at once; but, if 
pulse become fuller and more regular, heart-sounds more dis- 
tinct, less delirium, and restlessness, then continue it. 

Nutrition. — No beef-tea— cannot digest it, and little nourish- 
ment in it; give milk and lime-water, which is an antiseptic. 

Diarrhoea denotes intestinal changes from inflammation and 
subsequent intestinal catarrh. In early stages, leave it alone for 
first or second week. If it commence late (during latter part of 
third or fourth week), it is due to ulceration or sloughing. It 
should he arrested or held in check hy opiu7n hypodermically, in 
.small doses, and not by astringents. Stimulants can be adminis- 
tered at this stage. 

Tymjjanites.—JJse turpentine stupes to ahdomen. Dip a piece 
of flannel in boiling water, wring it out, pour turpentine over it, 
and apply to abdomen. 

Intestinal hemorrhage may cause death from exhaustion. If 
occurring late, should be promptly arrested. Patient must be 
kept in hed, and semi-narcotized with opium, given in small doses 
at intervals; must remain perfectly still in bed. If hemorrhage be 
profuse, patient must be kept under the influence of opium for a 
week or ten days. 

Peritonitis— Besith occurs as a result of general peritonitis 
from perforation in twenty-four hours. If without perforation, 
then semi-narcotize your patient for seven to ten days. Be careful 
of cathartics and enemata; do not use them, even if no passage 
occurs for two or three weeks. If stomach be irritable, use liypo- 
dermic injections of morphia over abdomen, sufficiently large to 
check peristalsis. 



272 



DISEASES OF THE BLOOD. 



Bronchitis. — If capillary bronchitis, apply dry cups to chest, 
and ammon. carb. internally. 

Pneumonia. — Stimulants should be given, or increased, if pre- 
\ viously used, at the time pneumonia occurs. 

Laryngitis. — Small blister below the angle of the jaw, and a 
poultice round the whole neck. If suffocation seem likely to 
occur, then perform tracheotomy. 

Subacute gastric catarrh.— Rest the stomach ; give 3 i. milk at a 
time, and hot fomentations over epigastrium. 

Bed-sores. — Scrupulous cleanliness and bathe the parts in spirits 
of camphor, and relieve the points of attack from pressure. If 
the sores penetrate the soft tissues, then wash frequently with 
carbolic acid, or brush the part over with equal parts of balsam of 
Peru and copaiba, and cover with dry lint and vaseline. If gan- 
grenous, use continuous warm bath, and so soon as sloughing 
takes place and parts separate, dress the parts with lint saturated 
in balsam of Peru and carbolic acid. 

Delirium. — Chloral, gr. x.-xx., and perhaps repeat in two hours; 
or give stimidants, if associated with insomnia, and especially if 
there be anaemia. 

Jactitations, etc. — Inject hypodermics of sulph. ether ( 3 i.) in 
four different parts of the body. 

Convalescence. — Eat often and little, such as milk, cream, jellies, 
gruel, animal broths. No solid food ; and, if diarrhoea be present, 
only milk and cream. No exercise, except walking about in sick- 
room. Patient should be kept in semi-recumbent position for two 
or three weeks after convalescence. If convalescence be slow, 
give small doses of quinine, iroii, and oleum morrhuce after food. 
If diarrhoea occur, keep patient in bed, give catechu and lia?ma- 
toxylin, and, if convalescence be delayed, then send him away for 
change of air. 

YELLOW FEVER. 
DEFINITION. 
Is a miasmatic-contagious, and also an infectious disease. 



YELLOW FEVER. 



273 



MORBID ANATOMY. 

The characteristic lesions, after death, will be found in the liver, 
kidneys, and the blood. 

Liver — is sometimes the color of fresh butter, mustard, coffee 
and milk, or chocolate. This change may be confined to one lobe 
or portion of the lobe, or it may extend over the whole liver. 
The organ contains less blood than normal, and is dry in appear- 
ance, softer than normal, and breaks down easily upon pressure. 

The microscope shows the hepatic cells infiltrated with oil 
globules, or there may be a granular change and disappearance of 
the cell-nuclei. This change is called " acute fatty degeneration." 

Stomach. — The mucous membrane is thick, red, and soft. 

Heart. — Is soft, flabby, lighter in color than normal, and the 
outline of the fibres is lost (from a degeneration which is taking 
place). 

Lungs. — Are the seat of hemorrhagic infarctions. 

Kidneys. — Are increased in size, due to an increase in the cor- 
tical substance. It is a true parenchymatous nephritis, in which 
the fatty stage is rapidly reached. The microscope shows the 
uriniferous tubules crowded with oil-glo*bules; in some places they 
are denuded of the epithelium, and in others filled with broken- 
down epithelium, which is undergoing a fatty and granular change. 

Brain. — Will be found hypergemic. 

Spleen. — Is darker, softer, and slightly enlarged, if at all. 

Skin. — ^Varies from a bright yellow to a dark orange-color. 

Blood.- Is changed in color; darker than in health; the globules 
have not the usual rounded outline ; their edges are serrated ; they 
break down easily, and rapidly undergo ammoniacal changes. 
The blood coagulates less rapidly and less perfectly than normal 
(this is due to a diminution or loss of the coagulating power of 
its fibrin). 

Other organs.— ThevQ is acute catarrh of the mucous membrane 
of the intestinal tract and larynx. The veins become turgid from 
intense hyperaemia often resembling varicosities. 

ETIOLOGY. 

This disease is rarely met with north of 40° north latitude, or 



274 



DISEASES OF THE BLOOD. 



south of 20° south latitude, and for its production it is necessary 
to have decomposing animal or vegetable matter, a certain 
amount of moisture, and a temperature which must be above 77% 
together with the specific poison. When the southerly winds pre- 
vail, the epidemic spreads and increases in severity, and when 
the northwest winds prevail, it is arrested, and its ravages are 
stopped so soon as the frost sets in. It is a portable disease, and 
occurs in sea-port towns. Its period of incubation varies from 
twelve hours to four or five days, or even several weeks. 

STAGES. 
Invasion — Remission — Exacerbation. 

SYMPTOMS. 

Ushering in Symptoms. 

General malaise — which occurs for two ortliree days previous 
to the attack. 
In mild cases. 

Chill — with or without rigors. 

Fever — continues from a few hours to two or three days. 
Temperature — varies from 102 to 110*^ F. : reaches its maximum 
at the end of second day (which is rarely higher than 105*^). 
Pulse — seldom above 100. 
Tongue — moist and somewhat coated. 
Headache — supra-orbital and intense. 
Vomiting — which is not prominent till late in the disease. 
Tenderness on pressure over the epigastrium. 
Constipation — which may be intense. 
Delirium — rarely violent. 

Pain — in the lower limbs especially in the calves of the legs. 
Eyes — red, irritable, watery or tearful. 

Fever abates or ceases after two or three days when a remis- 
sion occurs, commonly termed the state of calm. 
In severe cases. 
First stage. 

Pains, etc., may cease. 

Temperature — rises rapidlj', may reach as high as 110°. 



YELLOW FEVER 



275 



Pulse — seldom higher than 110 — termed the ''gaseous pulse.'' 
Is easily compressed and uncertain in character and vol- 
ume. It may fall below normal (even to 30 or 40), is 
small, weak and vibratory. 

Lividity of back — due to hypostatic congestion. 

Vomiting— projectile or regurgitant, a most constant and 
characteristic symptom. It comes on after the chill, con- 
tinuing throughout the whole course of the fever ; at first 
it consists of the contents of the stomach, and is alkaline, 
then of a thin liquid which may be of a red, claret, or 
brown color. Finally the black vomit appears, which 
may occur on the second or third day (but usually ceases 
from twelve to twenty-four hours before death); consists 
of pigment (produced by changes in the blood by the gas- 
tric juice) and globules (resembling blood); also epithelial 
cells from the mucous membrane of the stomach, degene- 
rated lymphoid cells and white blood globules. It is acid 
and has an acid taste without bitterness ; it may be acrid 
and excoriate the throat, tongue and lips. 

Tenderness over the epigastrium — which may be extensive. 

Tongue — usually red, dry and cracked but may be moist and 
covered with a creamy coating. 
Second stage (stage of remission — may last from a few hours to 
two or three <lays). 

Temperature — by the fourth day falls very rapidly, but usu- 
ally not below 100*^. It again rises quickly to 104'', re- 
mains stationary for 24 or 48 hours then falls to normal 
till convalescence is established. 

Evacuations — brownish or nearly black (due to presence of 
blood passing through the intestinal canal). 

Diarrhoea — rare. 

Albuminuria — frequent in grave and fatal cases. 

Urine — usually scanty and contains hyaline and granular 
casts, red blood corpuscles and renal and vesical epithe- 
lium. It is acid in the early stage and afterward alkaline 
due to the presence of bile when it may be of an orange 
color (from Vnle staining and l)loo(l). Previous to a fatal 
termination there is always complete suppression. 



276 



DISEASES OF THE BLOOD. 



Surface of the body — yellow (occurs after the paroxysm of 
fever). 

Eyes — red (like a ball of fire) and watery, and have a brilliant 
glassy transparent look. 

Jaundice — hepatogeneous (usually in fatal cases). 

Hemorrhages may occur from the stomach, intestines, kid- 
neys, bladder, uterus, nostrils, gums, etc. 

Petechioe and vibices — sometimes observed. 

Coma and convulsions — may occur (due to uraemia). 

Delirium — may occur (usually during the fever). 

Muscular prostration. 

Facies — suffering ; dejection ; anxiety ; anguish ; despair ; 
terror ; stupidity ; vacancy , astonislmaent ; sullen ; etc. 
Third stage — (stage of collapse or exhaustion). 
Prostration and feebleness. — Pulse, irregular. 
Extremities, cold. — Delirium, low. 

Indifference and apathy (as in epidemic cholera) showing ten- 
dency to death by asthenia. 
Restlessness — jactitations and great distress may occur. 
Death or convalescence. 

If convalescence occurs it is slow and preceded by fever with 
typhoid symptoms. 

DIFFERENTIAL DIAGNOSIS. 
From malarial fever; relapsing^ fever; bilious remittent; and 
acute yellow atrophy of the liver. 

PROGNOSIS. 

Is unfavorable. The duration of the fever is usually about six 
days. It often destroys life in three days. The average ratio of 
mortality is that, in every three cases during an epidemic, death is 
the result. 

TREATMENT. 

The patient must be quarantined; quinine administered daily 
(in gr. x. doses). Counter irritation should be applied over the 
region of the kidneys at the commencement of the attack, and 
calomel administered as a cathartic. It is better to combine 
the calomel with the quinine, giving gr. x. of each at a dose. 
Administer milk and lime-water, in order to overcome, if possible, 



SIMPLE INTERMITTENT FEVER. 



277 



the nausea and vomiting. Should there be restlessness with toss- 
ing and rolling of the head, it is best controlled by the hypodermic 
use of sulphate of morphine. As soon as the stomach can receive 
food, the composition of the blood should be improved by giving 
a most nutritious diet combined with wine, quinine, and iron, 

MALARIAL FEVERS. 

In order to produce these fevers, there must be a certain amount 
of vegetable matter and moisture on the surface of or in the soil. 
A temperature ranging from to 65° is required for its develop- 
ment. These fevers occur especially in marshy districts when 
covered by a thin sheet of water, and exposed directly to the 
sun, or when they have dried up; also when salt and fresh- water 
become mixed in the marshes; in damp-bottomed lands that are 
exposed to an annual overflow; or when new lands are opened up. 
The malarial poison may be conveyed by rivers which have their 
course in and flow through malarial districts, or it may be trans- 
mitted by the wind for a distance of about four miles and three- 
quarters. The limit for malarial fevers is 63" north and 57° south 
latitudes, seldom above an altitude of 2,500 feet. It can be 
prevented by free drainage, and may be arrested by cold. It is 
less virulent during the day than the night. The poison may be 
introduced into the system through the air we breathe and the 
food and water consumed. It is most liable to attack the weak, 
anaemic, and drunken. Taking cold over fatigue, sudden changes 
in the temperature, etc. , are apt to predispose one to an attack. 

SIMPLE IISTTERMITTENT FEVER. 
DEFINITION. 

Is a condition due to a malarial poison taken into the body 
through the lungs, food, etc. 

MORBID ANATOMY. 
The following are the constant pathological changes: Conges- 
tion of the internal organs; enlarged spleen and liver (due to hy- 
peraemia); more or less hyperaemia of the kidneys and mucous 
membran9 of the intestines. 



278 



DISEASES OF THE BLOOD. 



ETIOLOGY. 

The predisposing causes are intemperance; exposure to the night 
air; excessive fatigue; bad hygiene; and general depression. In 
children it is generally ushered in by convulsions. 

TYPES. 

(1) Quotidian — (most common) occurs in the morning. A 
paroxysm takes place every twenty-four hours, and lasts from 
eight to ten hours. 

(2) Tertian — occurs about noon, with a paroxysm every forty- 
eight hours, and lasts from six to eight hours. 

(3) Quartan — occurs in the afternoon or evening. A paroxysm 
takes place every seventy-two hours, and lasts from four to six 
hours. 

(4) Quotidian Double. — There are two paroxysms daily; the one 
severe and the other mild. 

(5) Tertian Double. — There are two paroxysms everj^ second 
day; as to-day, a severe chill and slight fever; to-morrow, a severe 
fever and slight chill, and so on. 

(6) xVlso a fever which occurs every seventh day, or multiple of 
seven. 

STAGES. 

Each of the types in this disease are characterized by a cold 
stage; a hot stage; and a sweating stage. 

> SYMPTOMS. 
Cold stage — (lasts from half an hour to three hours). 

Creeping coldness in the back, extending to the extremeties. 
Headache— (supra-orbital). 

Chills — lasting from half an hour to three or four hours. 
Urine — abundant and pale. 

Temperature - (elevated in the axilla or rectum). 
Surface temperature is below normal. 
Temperature per rectum is often 104°. 
Livid appearance of the skin, face, etc. — eyes sunken. 
The so-called " Goose-flesh " may exist, due to the erection of 
the papillae of the derma. 
Hot stage — (lasts from lialf an hour to two hours). 

Temperature— rises surldenly 106°-107° in the axilla. 



SIMPLE INTERMITTENT FEVER. 



279 



Pulse — rises. 
Tongue — dry. 
Great thirst. 

Intense heat and redness of the skin. 
Carotid pulsation. 
Great restlessness and uneasiness. 
Urine— high-colored and scanty; almost suppressed. 
Sweating stage — (lasts from one to two hours). 

Commences first on the forehead, when the patient goes off 

into a sleep, and wakes up much exhausted. 
Temperature — is about normal. 

DIFFERENTIAL DIAGNOSIS. 
From remittent fever and pyaemia. 

PROGNOSIS. 

In the simple form the prognosis is good. If malarial cachexia 
be developed, there is the enlarged spleen, and liver, and pig- 
mentation of tissue, which prejudices the life of the patient. 

TREATMENT. 

The patient must be kept in bed. Opium should be given in 
moderate doses hypodermically early in the cold stage, to diminish 
the severity of the attack. Quinine, gr. xxx. , should be admin- 
istered between the termination of one paroxysm and the liour 
when another is expected. 

In the cold stage. — The patient should drink hot water, or some- 
thing hot, and be covered with blankets, and hot water bottles 
applied to various parts of the body. 

In the hot stage. — The blankets should gradually be removed, 
and the patient be given cold drinks. When there is vomiting, 
opium should be used hypodermically. 

In the sweating stage. — The patient must be left alone. In 
order to overcome the paroxysms, give quinine, gr. xxx., one 
our previous to the expected paroxysm, if possible, in the form 
of a solution, as follows: gr. x. just before the sweating stage (or, 
gr iij. hypodermically), and gr. xx. one hour before the paroxysm. 



280 



DISEASES OF THE BLOOD. 



Keep the patient under cinchonism for a few days, or even one 
month, by giving quinine, gr. xv. every day, about two hours 
before the expected paroxysm. Remove the patient if possible, 
from the district. 

It is always of great advantage to give a good dose of calomel, 
gr. X., and jalap, gr. xv. at the commencement of the illness, as 
it will oftentimes avert the paroxysms; then resort to the quinine 
after the bowels have been evacuated. Pilocarpine, gr. ^, may be 
given hypodermically, to break up an attack. If the quinine does 
not act, commence by giving Fowler's solution, gtt. v., and increase 
the dose one drop every day till you reach gtt. xxx. ; having at- 
tained this maximum, commence again with gtt. xv. Philorid- 
zine, gr. xv.-xx. (the active principle of the apple-tree bark) may 
be given before each meal in cases where quinine has failed to 
afford relief. This drug is very little known, but has proved suc- 
cessful in the hands of many. 

PERNICIOUS FEVER. 
SYNONYMS. 

Congestive; climatic; ardent; African; tropical typhoid. 
DEFINITION. 

It is the most severe and dangerous form of malarial fever. It 
may assume any of the types of a periodical fever, but the quo- 
tidian and tertian are the most common forms. 

VARIETIES. 

Comatose; delirious; gastro-enteric ; algid; icteric; hemor- 
rhagic; and colliquative. 

MORBID ANATOMY. 
Is similar to the changes of intermittent and remittent fevers, 
but differs very much in degree, and will depend upon the severity 
of the fever. In the blood, the pigmentation is more abundant, 
and the pigment material may be in the form of granules, or 
plates, or have a cellular outline. On post-mortem, in some in- 



PERNICIOUS FEVER. 



281 



stances, the brain-substance will be more or less stained with pig- 
ment material; in others, minute blood extravasations, scattered 
throughout the substance of the organs, will be detected. Small 
blood extravasations into the spinal cord, with more or less pig- 
mentation, may produce tetanic spasms during life. Every organ 
in the body may be pigmented. The various organs may be 
markedly engorged. The spleen may be found softened, as well 
as enlarged, or it may have infarctions scattered through its sub- 
stance. The kidney and lungs are sometimes the seat of extensive 
hypersemia, causing great interference in their functions. 

ETIOLOGY. 

It differs from the simple forms of malaria only in degree. It 
prevails only in localities where the average range of temperature 
is 65°. 

SYMPTOMS. 

These frequently commence in the same manner as in intermittent 

or remittent fever. 
Comatose variety. 

After a remission, the patient passes into a state of stupor. 

Face — flushed. 

Conjunctiva — congested. 

Pupils — dilated. 

Respiration — slow, deep, stertorous, and, later on, increased 
in frequency. 

Pulse — slow (which becomes frequent as the disease advances). 

Temperature— 105° to 107° (in the axilla). 

Urine — retained. 

Bowels — niove involuntarily. 

It is usual, in about twelve hours, for a remission to take place, 
and the patient to awake, in a profuse perspiration, to con- 
sciousness; but, with the next exacerbation, the same symp- 
toms appear only with increased severity, and the patient 
passes into a fatal coma. 

Delirious variety. 

Delirium — violent in character. 
Face — flushed. 



283 



DISEASES OF THE BLOOD, 



Carotid pulsation. 

Eyes — injected. 

Tetanic spasms — may occur. 

Conjunctiva — congested. 

Memory of what has transpired seems lost. 

Pupils^dilated. 

Distinct intermission — may occur. 

Pulse — full and hard. 

Temperature— 107° to 108°. 
Attacks of delirium may be repeated three or four times. 
Gastro-enteric variety. 

Vomiting — excessive and purging. The materials vomited 
and discharged from the bowels are blood-stained. 

Sense of weight and burning in the stomach. 

Cramps — in the calves of the legs. 

Coldness and blueness of the surface. 

Pulse —small and almost imperceptible. 

Eyes — sunken. 

Face — resembling that of cholera. 
Thirst —intense. 

Inspirations— double, followed by a double sighing expiration. 
When fully developed, few patients recover. 
Algid variety. 

Surface of the body is cold. 
Rectal temperature — 104° to 107°. 
Sensation of burning. 
Thirst— intense. 

Cold perspiration covers the body. 
Pulse — slow, and finally disappears at the wrist. 
Tongue — white, moist, and cold. 
Breath— cold. Voice— feeble and sunken. 
When once this type is established, it progresses to a fatal term- 
ination, unless arrested early by treatment. 

Icteric variety. — This stage usually lasts three hours, and often 
terminates in death. 
Chill — long and continuous. 

Jaundice - appears first in the eye, but rapidly passes over the 
entire body. 



PERNICIOUS FEVER. 



283 



Copious vomiting of bile and a bilious diarrhoea. 

Headache— intense. 

Delirium — low and muttering in type. 

Pain— in the region of the liver and spleen, and over the kid- 
neys. 

Feeling of numbness in the limbs. 

Pulse — small, frequent, and hard. 

Urine — deep- colored . 
As the hot stage approaches, the 

Pulse — becomes more frequent. 

Respiration — labored. 

Temperature— 106° to 107°. 

Thirst — intense. 
If the sweating stage is reached, recovery usually takes place. 
Death usually occurs during two or three paroxysms. 

DIFFERENTIAL DIAGNOSIS. 
The comatose and delirious varieties may be confounded witli 
cerebral apoplexy, meningitis, or acute uraemia ; the gastro- 
enteric and algid with Asiatic cholera; and the icteric with yellow 
fever. 

Cerebral apoplexy. 

Hemiplegia —is usually present. 

Coma — sudden. 

Pulse — slow. 
Comatose and delirious varieties. 

Hemiplegia — rare; but, if present, occurs late. 

Coma — later; and, with the coma, a rise in temperature. 

Pulse — rapid. 

Asiatic cholera. 

Vomiting — projectile. 
Discharges — rice- watery . 
Urine — albuminous. 

Temperature — not so high as in the gastro-enteric and algid 
varieties. 
Gastro-enteric and algid varieties. 

Vomiting — excessive and blood-stained. 



284 



DISEASES OF THE BLOOD. 



Discharges — blood-stained . 
Urine -does not contain albumen. 
Yelloiv fever. 

New comers are almost certain to contract the disease. 
Jaundice — late. 
Urine — rarely bloody. 
Icteric variety. 

Those are seized who have been longest under the influence 

of the malarial poison. 
Jaundice — easly. 

Urine— frequently contains blood. 

PROGNOSIS. 

Is unfavorable, unless you can control the disease before the 
second paroxysm comes on. 

TREATMENT. 

On account of the alarming symptoms which follow so rapidly 
on each other, prompt and vigorous measures must be resorted to. 
Depletion in every form should never be practised. The only 
remedies which can be relied upon for controlling every variety 
of this disease are quinine and opium, which should both be 
given hypodermically. The following formulae for the solution 
of quinine are those employed by the English surgeons for this 
disease: quinise disulph., gr. 1. ; acid. sulph.,TrL v. ; acid, carbolici, 
Tii ij. ; aquae dest., § i. ; or, I^quiniee sulph., 3 i, ; acid, hydrobromici, 
3ij.; aquae dest., 3 vi. Thirty minims represent from three to 
four grains of quinine. From five to seven grains should be given 
every hour till the paroxysm has passed; after that, it should 
be given in three grain-doses every four hours. One-fom'th of a 
grain of morplmie should be administered with the first injection 
of quinine, and continued until the patient is brought fully under 
its influence. 

Warburg's tincture is claimed by many to have more control 
over this form of fever than quinine or morphia. One half ounce 
of this mixture is given undiluted after the bowels have been 
evacuated by a convenient purgative, drinks of all kinds being 
withheld, and in three or four hours after, the other half is ad- 



DENGUE FEVER. 



285 



ministered in the same way, when profuse, but not exhaustive 
perspiration, rapid decline of temperature, and abatement of 
headache take place. A second ounce of this tincture is seldom, 
if over, required. 

DENGUE EEVEK. 
SYNONYMS. 
* ' Break-bone fever; " and ' ' dandy " fever. 

MORBID ANATOMY. 
Is the same as that of the severer types of malaria, excepting 
that there is an exanthematous eruption which commences on the 
palms of the hands, extending rapidly over the entire body; it is 
also accompanied by arthritic changes, and enlargement of the 
external lymphatic glands. 

ETIOLOGY. . 

It may be either epidemic or sporadic, and attacks all classes 
and ages. It is a portable disease (some say it is contagious, 
which is questionable). It may be the precursor of yellow fever. 
It occurs particularly in the Southern States of America, and the 
severity of the attack depends upon the intensity of the poison. 
Its period of incubation is from three to five days. 

STAGES. 

Initiatory; fever; remission; and secondary fever and convales- 
cence. 

SYMPTOMS. 

Initiatory Stage. 
Headache. 
Photophobia. 
Great restlessness. 
Chilliness. 

Pain— in the back, limbs, and joints. 

Swelling of the small joints, and soreness of muscles. 
Fever — whicli lasts from twelve hours to four days. 



I 

286 



DISEASES OF THE BLOOD. 



Temperature — may reach 107°. 
, Pulse— 120 to 140. 
Face— flushed. 
Eyes — red and watery. 
Stage of Fever. 

Pain increases after the fever has lasted twelve hours and ex- 
tends down the sciatic nerve. 
Nausea and vomiting. 
Pain — in the epigastrium. 

Glands— swollen (axillary, inguinal, and cervical). 
Epididymitis — in some cases. 
Stage of Remission. 

Profuse sweatings —may occur. 
Diarrhoea —may occur. 
Epistaxis — may occur. 
Pains, etc. — diminish. 
Stage of Secondary Fever and Convalescence. 

Fever, and pains, etc. — return with greater intensity. 
Eruption— appears about the fifth day, first on the palms of ^ 

the hands, then on the neck, and spreads. It is of a 

papillary form, resembling scarlet fever. 
Tongue — is coated and dark-brown (like in typhoid fever). 
Heart — becomes intermittent. 
Glands — may suppurate. 

DIFFERENTIAL DIAGNOSIS. 

From rheumatism, remittent and relapsing fevers. 

From rheumatism — by the febrile symptoms which precede the 
arthritic pains, and the fact that the fever prevails epidemically. 

From, remittent fever — by the persistency of the rheumatic and 
neuralgic pains, eruption, and character of the remissions. 
PROGNOSIS. 

Is usually favorable. Is only unfavorable in the aged, and feeble 
infant. 

TREATMENT. 

It is customary in this disease to administer ipecac, calomel, and 
colchicum every night in cathartic doses. Calomel should never 



TYPHO-MALARIAL FEVER. 



287 



be given alone if its specific effects are likely to be produced. In 
order to relieve the pain in the head and limbs, colchicum should 
be given in combination with spirits of nitre and nitrate of potash 
(as a diaphoretic), in connection with an effervescing draught. 
During the remission, keep the bowels open by a saline cathartic, 
and give quinine combined with an alkali at stated intervals. For 
insomnia, narcotics may be given in small doses. Should there be 
exhaustion, the free use of wine and beer may be resorted to, and 
nutritious diet administered at stated intervals, day and night. 
The lymphatic enlargements (if any) should be painted with 
iodine. 

Citrate of quinine arid iron will be found of great service dur- 
ing convalescence. Should the joints remain swollen and tender 
for a long time, blistering the parts has been recommended. 

TYPHO-MALARIAL FEVER. 
DEFINITION. 

Is a fever produced by the combined action of a septic and 
malarial poison. 

MORBID ANATOMY. 

The changes which occur in this disease are confined to the 
blood, and the various internal organs. 

Blood. — The changes that occur in the vital fluid are similar to 
those in typhoid fever, combined with the presence of free pig- 
ment granules. 

Liver. — Is increased in size, and, on section, resembles the nut- 
meg-liver. It may resemble the liver of yellow fever or the 
bronzed liver of remittent fever. The microscope will show free 
fat, and brown pigment granules in the hepatic cells. 

Spleen. — Is enlarged, softened, and almost black in color. The 
Malpighian bodies are prominent. 

Kidneys. — There will be found a state of marked hypersemia in 
the cortical substance. 

Lungs.— There will be a hypostatic congestion at the most de- 
pendent portion of each organ. 



288 



DISEASES OF THE BLOOD. 



Heart. — Will be pale and flabby. There will be a granular de- 
generation of its muscular fibres. In its cavities will be found 
exsanguinated clots. 

Intestinal lesions. — As the foUicles enlarge, there is a tendency 
to the deposit of a black pigment. Extensive ulcerations of these 
follicles also take place, and they may invg,de the adjacent 
mucous membrane. These ulcerations are found principally in 
the ileum, and involving Peyer's patches; their edges are irregular 
and everted, and their base is of a grayish color, often mottled 
with dark spots. They may extend into the sub-mucous tissue, 
involve the muscular coat of the intestine, and even perforate the 
peritoneal covering. 

ETIOLOGY. 

It is only met with in malarial districts. Its development is 
favored by bad hygienic conditions, such as improper diet, over- 
crowding, bad sewerage, etc. ; it is never propagated by contact, 
or by morbid excretions, but it is a distinct malarial poison. It is 
reaUy a combination of two well-recognized forms of fever. 

SYMPTOMS. 

When the malarial element is predominant. 

Distinct chill, malaise, and pain in the limbs and back. 

Countenance — waxy, clay-colored, or of a yellowish tinge. 

Temperature — rises to 103° to 104° in a few hours. 

Pulse — full and forcible (usually about 100). 

Mental disturbance. 

Delirium — sometimes. 

Tenderness in the right iliac fossa. 

Nausea. 

Vomiting. 

Epigastric tenderness. 

Diarrhoea — usually present, and may precede the chill. 

Tongue — is at first pale, flabby, and has a smooth surface; it 
soon becomes covered with a yellowish- white coating; 
later, it becomes red and with a brownish coating, and in 
severe cases, it may suddenly become clear, red, and shin- 
ing. Sordes may collect on the teeth and lips. 



TYPHO-MALARIAL FEVER, 



289 



In fatal cases — towards the second or third week, the symp- 
toms resemble those of fatal typhoid fever, and the pulse 
reaches 130-140; is feeble and irregular; and coma and 
death ensue. In cases that recover, signs of amendment 
may be noticed about the tenth or twelfth day. 
When the septic element is predominant. 

General malaise. 

Chill — is distinct, or a complete Intermittent or remittent 

paroxysm may be produced. 
Temperature — may rise gradually or suddenly to 104^ to 105° 

within twenty-four hours. 
Remissions occur on every second or third day. 
Hepatic tenderness. 
Spleen— enlarged. 

Pulse — first week full, rarely above 100; but. during the 
second and third week, is small and compressible; and, in 
severe cases, it becomes intermittent (ranging from 110 to 
130). 

Tongue — swollen at first, with red projecting papillae and a 
light white coating ; afterward it resembles closely the 
tongue in typhoid fever. 

The surface of the body becomes dry and harsh. 

Skin — is of a bronzed hue. 

Jaundice — well marked. 

Urine — high-colored and scanty. 

Diarrhoea — may occur at any period, but is not usually exces- 
sive until the second or third week. The discharges have 
a very foetid odor, are watery and dark-oolored, and, in 
the later stages, may contain blood. 

Delirium — (which follows the headache) may be present, and 
is muttering in character, and other typhoid symptoms. 

DIFFERENTIAL DIAGNOSIS. 
It may be confounded with typhoid, remittent, relapsing, 
typhus, and yellow fevers. 
Typho-malarial fever. 

The advent is marked by a distinct chill; the rise in tempera- 



390 



DISEASES OF THE BLOOD. 



ture is sudden; there is a peculiar eruption which remains 
throughout the course of the fevers; there is a distinct 
periodicity in the febrile action: a jaundiced hue to the 
surface; and the blood contains free pigment. 
Typhoid fever. 

The symptoms come on insidiously; there is a typical range 
of temperature; on the sixth or eighth day a rose-colored 
eruption appears. , 
Typho-malarial fever. 

There will be enteric symptoms early; typhoid symptoms are 
developed as the fever advances. 
Remittent fever. 

There are no enteric symptoms, but it yields more promptlj^ 
to the use of quinine than typho-malarial fever. 
Typlio-malaHal fever may be easih^ diagnosed /?'o?» yeUoic fever ^ 
as, in the latter, the range of temperature is lower, and falls sud- 
denly on the third or fourth day; there will be also the circum- 
orbital pain; the appearance of the eye; the peculiar color of the 
skin; the character of the matter vomited ; the absence of diar- 
rhoea; the presence of albumen in the urine; and, finally, by the 
fact, that it is a portable disease, and prevails epidemically. 

PROGNOSIS. 

The septic is more fatal than the malarial type. The hygienic 
surroundings, previous habits of the patient, and range of atmo- 
spheric temperature will of course aid your prognosis. The 
average mortality is given as one in every twelve or twenty-four. 
The average duration of cases terminating in recovery is from 
three to four weeks. Capillary bronchitis and pneumonia are 
very dangerous when developed during the third week. 

TREATMENT. 

Depends entirely upon the type of the disease. Prevent the over- 
crowding in the houses: remove your patient, if possible, from his 
present surroundings; improve his diet thoroughly: and by these 
means you will prevent the development of a poison wliich gives 
to this fever its typhoid type. In cases wliere the malarial ele- 



TYPHUS FEVER. 291 

ment is prevalent, administer quinine (^rs. xx.-xxx.) in two or 
three doses of gr. x. each every hour until the desired quantity- 
has been given. In the septic variety, quinine has no effect. By 
some, arsenic is claimed to have a specific influence over this form 
of the disease, but its beneficial effect is due to its power over 
malarial affection, and not to its specific influence over the fever. 
In fact, the treatment may be said to be almost identical with that 
of typhoid fever. 

TYPHUS FEVEE. 
SYNONYMS. 

Ship fever; hospital fever; Jail fever; camp fever; petechial 
fever; putrid fever; continued fever; fourteen days' fever; cerebral 
typhus; exanthematous fever. 

MORBID ANATOMY. 

The first changes that take place are in the blood, which is 
darker than normal, and when drawn during life, coagulates im- 
perfectly or not at all; but, if it does, the clot is of the consistency 
of putty. The fibrin is diminished and loses its power of coagu- 
lation. The red globules first increase, and then diminish, and 
urea and ammonia are found to be in excess. The blood when 
drawn rapidly undergoes ammoniacal decomposition, 

The microscope shows the red blood-globules to have lost their 
outline; they have serrated and irregular edges, and undergo de- 
generation. The coloring matter passes through the walls of the 
vessels and stains surrounding tissues. 

Parenchymatous degeneration next takes place. The blood 
rapidly undergoes decomposition after death, even sooner than in 
typhoid fever, often beginning before death. The muscles are of 
a brownish color, dry, and granular. The liver and spleen under- 
go similar degeneration. In the kidneys, the changes are much 
more extensive and constant than in typhoid fever; tlie cortical 
substance is swollen, opaque, and fatty, and is marked by a cloudy 
swelling of the epithelium in the renal tubes. This cloudy swell- 
ing also occurs in the heart-fibres, causing flaccidity, and giving 



292 



DISEASES OF THE BLOOD. 



to the heart a dark-brown color. There is often serum in the peri- 
cardium ; clots occur in the cavities of the heart, and thrombi on 
the walls of the veins. Ulceration of the mucous membranes of 
the mouth and larynx ensues, involving the sub- mucous tissues. 
Splenization of the lungs takes place, and the cerebral vessels be- 
come congested. The sinuses and blood-vessels in the brain are 
engorged, so that they will stand out prominently when the cal- 
varia is removed, and there will be more or less effusion, in the 
meshes of the pia mater (often from eight to ten ounces). If the effu- 
sion be turbid, it is an indication that there has been meningitis. 
If the effusion be abundant, the sulci are deepened and the con- 
volutions are sharpened in outline. 

Abdominal lesions. — Intestinal changes are absent. There is no 
ulceration of the glands excepting changes which have taken 
place from congestion (causing the shaven-beard appearance in 
Peyer's patches). 

Complications. — These may be pulmonarv% cerebral, or spinal. 

The pulmonary include bronchitis, catarrhal pneumonia, pleu- 
risy, congestion, oedema, pulmonary gangrene (from pneumonia), 
and laiyngitis (from extensive bronchitis). 

The cerebral or spinal include meningeal inflammation with 
serum in the meshes of the pia mater; but. besides this sub-arach- 
noidean effusion, there must be also plastic exudation; the arach- 
noid has lost its shining color and is thicker than normal. 

There will be active delirium; contracted pupils; pulse, slow, full, 
and then rapid, and irregular, and intermittent, and the urine is 
often passed with difficulty. The parotid, sub-lingual, and glands 
of the neck become greatly enlarged, so as to interfere with deglu- 
tition and to often cause death. The inguinal glands may become 
so enlarged as to interfere with the return circulation. There may 
be a swelling of the lower limbs from degeneration and feebleness 
of the heart, causing retarding of the circulation and thrombi in 
the superficial veins. Suppuration and cellulitis may occur, result- 
ing in extensive abscesses. 



TYPHUS FEVER. 



293 



SYNOPSIS OF THE FOREGOING PATHOLOGICAL 
CHANGES. 

The changes that take place occur in the skin, organs, and 
blood. 

In the skin—fhe mulberry rash will be present on the side of the 
chest and abdomen, and possibly on the extremities; it dis- 
appears on pressure (for three days) and the spots are dark in 
color and somewhat elevated. 

In the brain— thevQ is hyperasmia of the vessels of the convexity; ' 
meningeal exudations: serous effusion into the meshes of the 
pia mater and ventricles; the arachnoid becomes opaque and 
dotted with yellowish spots. 

In the alimentary canal — changes take place in Peyer's patches 
(producing the " shaven-beard " appearance). 

Complications. — Bronchitis, pneumonia, splenization of the lung, 
pleurisy, oedema, meningitis, parenchymatous nephritis, and 
finally ulceration of the larynx, pharynx, and mouth, and 
enlarged cervical and probably inguinal glands. 

In the blood. — All the common lesions of fevers (see page 316), and 
a marked increase in urea. 

ETIOLOGY. 

This disease is due to a specific poison, communicated from the 
sick to the healthy by contagion only. Over- crowding and bad 
ventilation favor the spread and increase the severity of the dis- 
ease. The poison passes into the blood mainly through respired 
air. 

SYMPTOMS. 
Initial symptoms — come on suddenly, and include: 
Vertigo. 

Loss of appetite. 
Chill. 

Steadily increasing frontal headache. 
Pain— in all the limbs (especially the thighs). 
Extreme prostration. 

Tottering gait — the patient is then compelled to take to liis 
bed. 



294 



DISEASES OF THE BLOOD. 



1st Week. — Temperature — 104°-105°, morning and evening varia- 
tions are slight; it rises one or two degrees. 

2d Week. — Temperature — is liable to sudden depression, but gener- 
ally falls at this period. If it continue, it denotes development 
of cerebral symptoms, commencing with this sudden depres- 
sion. It is usually highest on the second or third day of the 
disease. 

Tongue — is first swollen, white, and coated ; then of a yellowish- 
brown color, and thick ; and, later on, becomes dark, dry and 
fissured. 

Delirium — low, muttering, or active (often becomes furious about 
the eighth day); it comes on early and continues till the end 
of the disease. 

Coma-vigil — patient has horrid fancies and visions, and is abso- 
lutely indifferent as to what is going on, and lies with his eyes 
wide open. Is usually followed by a fatal termination. 

Headache — severe and persistent for the first ten days. 

Stup or and somnolence — seldom absent. 

Paralysis of the sphincters of the anus and bladder or, of the 

mucous coat of the bladder (causing retention). 
Dysphagia and partial or complete aphonia. 
Picking at the bed clothes, and subsultus tendinum. 
Heart— the first sound may be inaudible. 

Pulse — during the second week the pulse may be small and feeble 
140 or 150, which is unfavorable; is generally 100, frequent, 
soft, rapid, easily compressible, and irregular; if 120 for three 
days in the first week, it denotes danger. 

Urine— is first diminished, and then increases, and will contain a 
small amount of albumen; or, if it be a severe case, albumen 
will be large in quantity, and there will be renal casts, also 
epithelium and fatty casts of the uriniferous tubes. 

Eruption — {called the mulberry rash) — consists of small, irregular- 
shaped, dark, brick-dust spots; is slightly elevated at first, 
and remains throughout the disease. It appears on the fifth 
to the seventh day of the fever, and disappears on pressure (for 
the two first days of the eruption). Is present upon the sides 
of the chest, abdomen, and possibly on the extremeties. 



TYPHUS FEVER. 



295 



Constipation. 

Countenance — dull, heavy, and, later on, of a mahogany color. 

CAUSES OF DEATH. 
Death may result from meningitis, pneumonia, capillary bron- 
chitis, gangrene, exhaustion from the effects of poison, Bright's 
granular kidney, coma and syncope. 

DIFFERENTIAL DIAGNOSIS. 
From typhoid and relapsing fevers; measles; pneumonia; acute 
Bright's disease; meningitis; delirium tremens; erysipelas; pyae- 
mia; and septicaemia. 

PROGNOSIS. 

Is always grave. It depends upon the age of the patient, the 
character of the epidemic, and the complications. With the in- 
temperate, it is likely to prove fatal. 

In cases where debility exists from advanced age, intemperate 
habits, privation, previous disease, mental depression, over-crowd- 
ing, bad ventilation, and gouty diathesis, the prognosis is always 
dangerous. 

TREATMENT. 

Quarantine your patient, as it is a contagious disease. Thor- 
oughly disinfect the premises for two or three days, at the time 
and after the disease. The patients should be placed in pavilions 
or tents in order that they may have plenty of fresh air. Remove 
all windows regardless of cold, and supply plenty of blankets. 

Medical treatment.— Fresh air is the only remedial agent. First 
reduce the temperature, and then sustain the heart's power. Ad- 
minister quiniyie and apply cold to the surface. Milk should be 
the only diet, and water may be drank freely. If the temperature 
be 104°, put the patient in a bath 10° lower than the temperature 
of the body. Ice or cold water may be added to the bath till the 
temperature falls to 68° or 70°, and the patient kept in it till his 
temperature falls to 101° or 102°; then he should be taken out, 
dried quickely, and put into bed. Should the temperature rise 
again, repeat the bath. If there should be intense pain and 
delirium after taking the bath, put ice-bags to the head. 



296 



DISEASES OF THE BLOOD. 



Give quinine — gr. Ix. in two hours, with gr. x. pulverized digi- 
talis added. 

Stimulants (?). — Patients under twenty-five years of age rarely 
require it unless they happen to have been intemperate prior to 
the attack. To the old and feeble, when occasionally administered, 
it probably does good. You should always watch your patient 
when administering stimulants, as in typhoid fever. One ounce 
in twenty-four hours is all that is necessary, and then only to sus- 
tain the heart's power. 

Cardiac sedatives. — Veratrum, aconite, and digitalis may be 
administered. For failure of the heart's power, give digitalis 
3 iv.-vi. in twenty-four hours, or quinine and digitalis in the same 
proportions. 

For insomnia — keep the room dark and quiet, give opiates in 
full doses, and apply cold to the head. 

For insomnia and delirium— give chloral gr.-x.-xv. 

For stupor — if occurring early, give coffee, musk, camphor, or 
cold douche. 

For coma — valerian and phosphorus may be given, but they 
are not efficacious. 

If the patient cannot take quinine by the mouth, give it by the 
rectum, about one-third more than by the mouth, thus, quinine 
dissolved in acid causes it to become disulphide or in the form of 
a suppository of the bisulphide by the rectum. 

EEMITTENT FEYER. 
SYNONYMS. 

Southern ; Western ; African ; continued ; bilious ; and accli- 
mative. 

DEFINITION. 

Is one of the malarial fevers, characterized by a sudden invasion 
and persistent high febrile symptoms ; temperature frequently 
rising to 105°-106°. 

MORBID ANATOMY. 
It is the result of malarial poisoning ; consequently there is di- 
minution in the red blood-corpuscles ; and pigment granules 
exist (due to hoemoglobin which has escaped from the red blood- 
corpuscles in the vessels, and developed in the liguor sanguinis, 



REMITTENT FEVER. 



297 



and which may infiltrate into the adjacent tissues and cells). The 
changes resemble those occurring in intermittent fever. The 
principal lesions will be found in the spleen, liver, stomach and 
intestines. 

Spleen. — Is enlarged and bronzed (though not so much as in in- 
termittent fever), from congestion of the vessels, and an excess 
of pigment. 

Liver. — (called the " bronzed liver ") is not much increased in size. 
The peculiar color is due to pigmentation of the tissues 
'throughout the organ. This is the characteristic lesion of 
the fever. 

Stomach. — The mucous membrane is more or less congested, 
thickened, and softened. 

Intestines. — The mucous membrane is more or less congested 
thickened, and softened. Peyer's patches are enlarged and 
have the " shaven beard " appearance. Sometimes ulceration 
of the intestines occurs, or there may be simple hypersemia of 
the mesenteric glands, due to a catarrhal inflammation. 

ETIOLOGY. 

The predisposing cause is malarial fever. Remittent fever may 
pass into intermittent during convalescence. It occurs chiefly in 
63° north and 57° south latitude. It prevails along the banks of 
rivers. The miasm may be conveyed by the winds. It occurs in 
marshy regions where there is but little water. 

SYMPTOMS. 
REmTTENT Fever. 
Premonitory symptoms. 

Oppression in the epigastrium. 

General malaise and sudden development of symptoms. 
• Cold stage. 

Chill — short and not severe (a general coldness). 
Temperature — rises about 3° above normal during the chill. 
Headache — intense. 
Pain in the hack and limbs. 
Hot stage. 

Fever — which follows the chill, when temperature rises rap- 
idly and within 12 hours may have reached 105° or 106°. 



298 



REMITTENT FEVER. 



Pulse — increases with the temperature (reaches 110 to 130). 

Face — flushed. 

Eyes — suffused. 

Conjunctiva — conjested. 

Great restlessness. 

Nausea — persistent and distressing. 

Vomiting — consists first of contents of the stomach, then 
stringy mucus tinged with greenish matter, and finally a 
slight black vomit. 

Great oppression and tenderness in the epigastrium, unre- 
lieved by vomiting. 

Symptoms increase in severity for 12 hours, ivhen folloivs the 
Remission stage. 

Perspiration — not profuse — commences on the forehead, ex- 
tending over the entire body. 

Temperature — falls 1° or 2° (but there are still evidences of 
fever, as it does not reach normal). 

Pulse — suddenly falls 10 or 20 degrees. 

Thirst — diminishes. 

Vomiting — decreases. 
Period of exacerbation — occurs at the same time on the following 

day when all symptoms return with increased severity. This 

constant change may continue for a week and the fever be- 
comes a continued one when 

Tongue — may be parched and sordes may be present upon the 
teeth. 

Countenance — dull and heavy. 

Distress and pain and tenderness in the epigastrium. 
Constijmtion — which may give way to diarrhoeal discharges 

of a brownish character with fullness of the stomach and 

local tympanites. 
Typhoid symptoms — then come on as in the third week of 

typhoid fever. 

Bilious Remittent. 

Vomiting — bilious. 

Jaundice of the skin — like yellow fever. 
Tenderness over the region of the liver. 



SMALL-POX. 



299 



DIFFEREFTIAL DIAGNOSIS. 
From intermittent fever ; typhoid fever ; bilious remittent fever; 
yellow fever ; pyaemia; septicaemia and typho-malarial fever. 

PROGNOSIS. 

In a simple case the prognosis is always good. Even cases of 
severe types should recover if properly managed. The average 
duration of this fever is two weeks . 

TREATMENT. 

The patient must be placed under the best possible hygienic sur- 
roundings, and the same arrangements carried out respecting the 
sick room as in typhoid fever. Quiniyie must be given during the 
exacerbrtion (paroxysm) or remission, in doses varying from gr. 
x-xx according to the severity of the fever, and repeated every two 
hours till cinchonism is produced. If, after the free use of quinine 
the exacerbations be more severe, the remissions less frequent 
and typhoid symptoms manifesting themselves, stimulants may 
be resorted to, and probably in large doses, while passing through 
this period. 

The surface of the body should be sponged with cold water if 
the exacerbations be intense, the headache very severe and the 
restlessness or fever are not relieved by the quinine given in large 
doses. 



SMALL-POX. 

SYNONYM. ^ 
"Variola" or "varioloid." 

VARIETIES. 

Variola discreta (separated variola). 
Variola confluens (the spots running into each other). 
Variola hemorrhagica (the eruption being black, on account cf 
hemorrhagic effusions). 



300 DISEASES OF THE BLOOD. 

MORBID anatomy! 

1st. There is congestion of the organs, as of the brain, lungs, 
liver, spleen, and kidneys. 

3d. There is the state of granular or acute fatty degeneration 
(resembling changes due to phosphorus poisoning). 

3d. There is the state of fatty degeneration of the liver, kid- 
neys, and heart (which is usually yellow, flabby, and brittle). 

4th. There are small hemorrhages into nearly every viscera, 
with ecchymosis of the serous membranes and fluid blood in all 
the cavities. 

The characteristic lesion is the eruption upon the mucous mem- 
brane and skin. At first, a congestion of the papilla, sometimes 
uniform, and sometimes in spots, giving rise to little red spots on 
the surface, may be perceived, which are surrounded with cells 
rapidly undergoing granular degeneration. These papules are due 
to changes in the surrounding cells in the rete Malpighii, and in 
the capillaries, and to certain new cell infiltrations. 

A serous infiltration on the surface of the papule now develops, 
called the vesicle (consisting of blood serum, which has escaped 
through the walls of the capillaries). The centre of the vesicle 
becomes umhilicated (depressed), due, probably, to the serous in- 
filtration taking place more rapidly at the periphery of the vesicle 
than at the centre, causing elevation of the periphery, although 
it has been explained in other ways (adhesion of centre of vesicle 
to the hair of the skin, formation of lymph-bands in the vesicle, 
etc.). 

The vesicle next changes color, due to migration of white blood 
and pus corpuscles from the capillaries into the surrounding 
tissue, sin.dit\\eii becomes a pustule. Destruction of the tissues at 
the point where the papillary congestion first occurred takes place. 
If the superficial layer of the skin be only affected, there is no 
scar left; but, if the inflammation extend to the deeper cellular 
tissue, sloughing occurs, resulting in cicatrix and pitting. 

After the pustules have formed, the inflammatory products dry 
down, and a crust is formed, which contracts in the central por- 
tion. These crusts separate when the inflammatory process sub- 
sides, and recovery takes place. These lesions are not conflned to 



SMALL-POX. 



301 



the skin, as they may also form on the mucous membrane of the 
stomach, intestines, bronchial tubes, larynx, and conjunctiva, 
urethra, etc. 

SYNOPSIS OF THE FOREGOING. 

The lesions of this disease occur in the skin, mucous membrane, 
organs, and blood. 

In the skin. — All the stages of the eruption may exist, which in- 
clude the macule, papule, vesicle, umbilicated vesicle, pustule, 
scab, or cicatrix; also, possible abscess, ulceration, and local 
sloughs. 

In the mucous membrane. — The same conditions are possible in 
the urethra, eye, nose, mouth, alimentary canal, and middle 
ear. 

In the organs. — Parenchymatous nephritis, oedema glottidis, 
evidences of complications, as pleurisy, pneumonia, peri- and 
endo-carditis, meningitis, and bronchitis, and fluid blood, 
may be found in some of the capsules. 

In the blood. — The common lesions of fevers (see page 310). 

ETIOLOGY. 

It is propagated only by contagion; by means of the breath and 
exhalations from the skin; the poison may pass through the at- 
mosphere for a distance of about two and a half feet in the open 
air. It may be contracted by entering a contaminated room. It 
can be conveyed l^y clothing, but the clothing must contain pus 
or crusts from the small-pox virus. It attacks all periods of life. 

Stage of infection. — This may occur during the period of sup- 
puration, or the stage of desiccation, or even during incubation. 
Tlie poison is absorl)ed by the mucous membrane of the respiratory 
tract durnig respiration. 

Tlieperiod of incid>ationv ?iries from ten to thirteen days; if the 
poison be introduced from inoculation, forty-eight hours may only 
elapse before the stage of initiatory fever takes place. 

STAGES. 

Incubation. Invasion. Eruption. Suppuration. Desiccation. 



302 



DISEASES OF THE BLOOD. 



SYMPTOMS. 

VARIOLA DISCRETA. 

Period of incubation and invasion. — (The invasion may be sud- 
den or gradual.) 
Chill and pain in the head, back and loins. 
Temperature — elevated, 104 "-ICS" (may reach as high as 107°). 
Pulse — may rise from 100 to 120, and even 140 per minute, 

and may be full or more frequent. 
Nausea and vomiting. 

Soreness of the throat and pain in the pharynx. 

Delirium— about the thu-d day (may occur). 

Face — flushed. 

Photophobia. 

Headache. 

Throbbing of the carotids. 

Conjunctiva — congested. 

Great restlessness. 

Countenance — anxious and flushed. 

Somnolence. 

Respiration — short, frequent, and labored. 
Cough —stridulous . 

Voice — husky, if the larynx be involved. 
Vertigo and convulsions (in children). 
Excessive languor. 
Anorexia. 

Stage of eruption — on the third day after the initial fever. 

Eruption — usually commences first along the edges of the 
hair; next on the forehead, nose, and upper lip; then on 
the body and extremities, a day or two later; and, lastly, 
on the hands and feet. It is of ?i pale-red color, resem- 
^ bling^ea bites, and about the size of a millet-seed or pin's 
head; there is a sense of burning or itching on the sur- 
face, and it is less abundant on the body and extremities 
than on the face. On tlie second day, it becomes darker, 
elevated, and papular. On tlie tliird day, it becomes 
more conical, and a vesicle forms at its apex. On tlie 
fourth and fifth days, it is spherical and about the size 



SMALL-POX. 



303 



of a pea, and as it enlarges, becomes umbilicated, the 

fever then subsides, and all pain is gone. 
Stage of sux)purat''on, or seeondary fever. 

Suppuration — begins about the eighth day of the eruption 

with the following symptoms : 
ChUl. 

Temx)erature — rises rapidly, perhaps higher than it did during 
the initial fever, sometimes as high as 108°-109°; it reaches 
its maximum when suppuration is at its height (about 
the ninth day) on the extremeties. 

Pulse — becomes frequent. 

Face — is a shapeless mass and swollen (if the eruption be 

abundant). 
Itching — intolerable. 
Breath — sweetish and of a sickly odor. 

Skin — becomes red and tumefied; and if the spots be thickly 
set, they become confluent. 
Stage of desiccation. 

Desiccation — commences from the eleventh to the fourteenth 
day of the eruption, when the pustule either ruptures, 
discharges its contents, dries up and forms a yellow crust, 
or shrivels and dries up without rupturing. 

The symptoms abate. 

Scabs — come off (about the eleventh to the fourteenth day). 
Skin— is of a red-brown color (lasting from five to six weeks). 
Appetite — returns. 
Convalescence — is established. 

VARIOLA CONFLUENS. 

The duration is short and severe, only lasting about forty-eight 
hours. 

Stage of eruption. 

Eruption — appears simultaneously all over the body; the spots 
are very numerous, especially on the face and hands. On 
the first day they are almost confluent ; on the second day 
the skin is intensely red, and swollen, and vesicles form 
which become confluent. It may involve the mucous 
membrane of tlie moutli, throat, nares, and larynx, re- 
sulting in impossible deglutition. 



304 



DISEASES OF THE BLOOD. 



Temperature— rises to 103''-104° till suppuration takes place. 
Typhoid symptoms set in. 
Tongue — becomes dry. 

Patient is semi-comatosed with sub sultus, low delirium, and 

intense nervous depression. 
Urine — albuminous. 

Glands — parotid and sublingual enlargements may occur. 

CEdema glottidis — may suddenly develop, which will cause 
death, unless laryngotomy be performed early. 
Stage of suppuration. 

Suppuration — steadily follows, forming flattened yellow-col- 
ored confluent patches, which run together. Large bullfe 
filled with sero-purulent fluid are thus produced, and 
these may spread over the face so as to render the patient 
perfectly unrecognizable. 

Temperature — is higher than in the stage of eruption. 

Vomiting — may be violent. 

Diarrhoea. 

Delirium. 

Coma. 
Stage of desiccation. 

Desiccation — is slowly reached; large concentric crusts are 
formed, adhering to the skin, and beneath there is sup- 
puration of the papillary layer, with extensive destruction 
of the true skin, causing ugly pits and scars. 

The initial fever often reaches 106'' to 107°, and in severe types 
110°, and pulse is frequent and feeble. 

COMPLICATIONS. 

Inflammation of the serous membranes, especiall}^ pleurisy, 
peri-carditis, croupous and catarrhal pneumonia, severe bronchial 
inflammations, and uraemia. 
Variola hemorrhagica . 

This is a modified form of the other two varieties, only differing 
in the 

Eruption — which is very dark over the whole body. There is 
also 



SiklALL-POX. 



305 



Hemorrhage — from the various mucous membranes of the 

body ; and in females profuse menorrhagia. 
Suppuration — is seldom reached. 

Death — results from exhaustion, due to hemorrhage, or from 
the effects of the small-pox poisoning. 

CAUSES OF DEATH. 
Death from small-pox may occur from oedema glottidis; general 
bronchitis; pneumonia; or acute fatty degeneration of the kidneys. 

DIFFERENTIAL DIAGNOSIS. 

It is more prudent to wait till the third day of the fever before 
venturing on a diagnosis, when the eruption will be well out and 
the vesicle found. It may be mistaken for measles, typhus, and 
meningitis, petechial eruptions, and chicken pox. 

Small-pox — commences with chill and elevation of tempera- 
ture; the temperature is very high, 106^ -107% and falls as soon as 
the eruption appears. 

JfeasZes— commences with coryza, sneezing, redness, and suffu- 
sion of the eyes; the temperature rises after the eruption appears. 

Small-pox — the eruption appears on the third day, and is first 
seen on the face and forehead. 

Typhus fever — (is difficult) there is greater loss of muscular 
power, and the eruption is first seen on the abdomen. 

In Small-pox — the face is pale, and bears an anxious look. 

In Meningitis — the face is flushed and deepens. 

PROGNOSIS. 

Depends upon the eruption, type of the disease, and age of the 
patient. In variola discrete— unless complications exist, recover}^ 
usually takes place (from oneto five die). In variola confluens — 
the x)rognosis is more grave; one-half of the cases are generally 
fatal. In variola hemorrhagica — is usually fatal in forty-eight 
hours; and is more fatal in summer than in winter. If the patient 
has been of intemperate habits, is syphilitic, or a chronic case, 
the prognosis is bad. Whenever there is an abundance of the 
eruption, the prognosis is bad. When the urine becomes scanty 



306 



DISEASES OF THE BLOOD. 



and high-colored at the commencement of the stage of suppura- 
tion, you may be sure there are kidney complications, and con- 
vulsions may occur, resulting in coma and death. 

TREATMENT. 

The best mode of procedure is to treat the special symptoms as 
they arise. The patient should be quarantined, placed in bar- 
racks, or large well-ventilated apartments, at a temperature not 
below 60° F., and where pleiity of fresh air can be obtained. If 
the temperature rise to 107° or 108°, appl}^ cold to tlie surface, and 
give antipyretic doses of quinine. Should the headache be severe, 
and tlie face flushed, ice-hags apj)lied to the head may wonder- 
fully relieve the patient. For vomiting, let him drink iced car- 
bonic acid water, and should it be attended with restlessness and 
delirium, morphine, administered hypodermicaUy, is indicated. 
When there is depression, stimulants must be given. If the 
mouth and pharynx become involved, ice, cold carbonic acid 
water, may be given, and use a solution of muriated tinct. of 
iron, or carbolic acid, or permanganate of potash, as a gargle. 

In order to prevent pitting, cold applications, and rupturing 
each vesicle before it becomes a pustule, has been found bene- 
ficial. 

As a preventive to the disease, vaccination should be per- 
formed with bovine virus or lymph. 

SCAELET FEVER. 
DEFINITION. 

Is an inflammation affecting the tegumentarj' investment of 
the entire body, both cutaneous and mucous, and accompanied by 
fever of an infectious or contagious character. 

VARIETIES. 

Scarlatina simplex; scarlatina anginosa; scarlatina maligna. 

MORBID ANATOMY. 
The lesions occur in the skin and mucous membranes. 
The eruption appears on tlie second and third days of the fever; 



SCARLET FEVER. 



307 



it consists of closely aggregated points about the size of a pin's 
head, with normal skin between these aggregations. The red 
spots are circular, and tend to become confluent. The skin may 
be turgid and swollen. The color changes with the fever, show- 
ing, wlien very red, that there is a liigh. fever. The redness 
will, during tlie first forty-eight hours, if respiration be unim- 
peded, disappear under firm pressure, and reappear almost 
dh-ectly. The eruption may only appear on the face. The period 
of desquamation follows tlie period of decline in two or three 
days, and is due to an excessive production of newly-formed epi- 
dermis. The most frequent change in connection with those of 
the cutaneous surface is catarrhal pharyngitis. The tonsils become 
red, swollen, of a dry appearance, and covered with tenacious 
mucus. These changes may disappear in a few days, or become a 
dark livid color, and oedematous (associated with dysphagia, from 
oedema); inflammation of the parotids and otlier glands may also 
occur, often terminating in suppuration, or diffused necrosis, or 
gangrene of the tonsils, followed by abscesses, destroying the 
cell-tissues and sloughing of the skin in that region, and fatal 
hemorrhage. 

This disease, in the early stages, is often complicated by diph- 
theria. During the eruptive stage, the ear (middle ear), as well 
as the throat, may be greatly affected. The kidneys are more 
affected in this disease than any other organ; catarrh of the 
uriniferous tubules, or croupous inflammation of the same in the 
cortical substance, commencing in the Malpighian tufts, may be 
developed. In a well-marked case of scarlatina nephritis, the 
epithelial cells of the tubules will be clouded, enlarged, changed in 
shape and position, and destroyed. The kidney may liave the 
appearance of an interstitial nephritis. On post-mortem examin- 
ation, there is found to be congestion of the brain, liver, spleen, 
etc., and softening of the liver and spleen. The mucous mem- 
brane of the intestines has become affected, and there is the 
"shaven beard" appearance in Pej^er's patches. 

SYNOPSIS OF THE FOREGOING. 
The pathological lesions are confined to the skin, mucous mem-, 
brane, organs, and blood. 



308 



DISEASES OF THE BLOOD. 



In the skin — you may have the characteristic eruption before 
death, and evidences of desquamation in patches, or of local 
abscesses. 

In the mucous membrane — there maj- be suppuration in the 
vicinity of the throat; ulceration of the tonsils, Eustachian 
tube, middle ear, and possibh^ of the cornea. 

In the organs — desquamative nephritis, and evidence of some of 
the possible complications, such as pneumonia, pleurisy, peri- 
and endo-carditis, and neurosis of the middle ear. 

In tlie bZoocZ— all the common lesions (see page 316). 

ETIOLOGY. 

This is a frequent disease of childhood, but may occur at any 
age. It is of a contagious nature, and may be conveyed directh^ 
from the affected to the healthy by contact: also througli the at- 
mosphere, or by clothing which has become saturated with the 
poison. It is apt to attack any or every member of a family, and 
is most infectious at the i)eriod of desquamation. The period of 
incubation is from two to ten days, but generally from four to 
seven days. Its regular course is from two to three weeks. 

STAGES. 

Stage of invasion — eruption — desquamation. 

SYMPTOMS. 

Stage of Invasion — (from twelve hours to four to five days). 
Chilliness and slight rigor. 
Headache. 

Temperature— elevated, 103°-104°. 
Pulse— accelerated, 120-130. 
Face — flushed, dry, and red. 
Throat — sore. 
Neck— stiff. 
Joints— tender. 

Vomiting — jirojectile in character 
Thirst. 

Tongue — red, and strawberry color. 



SCARLET FEVER. 



809 



Lassitude and pain in the back and limbs. 
Restlessness. 

Convulsions — in the very young or in the aged. 

Delirium— in the very young or in the aged. 

Coma — in the very young or in the aged. 
Stage of Eruption. 

Eruption — comes on twenty-four hours after the fever of in- 
vasion, and is of a bright rose color, if the attack be mild; 
or deep red (boiled lobster) color, if the attack be severe; 
it appears, first, on the neck and upper part of the chest 
and coalesces, extending over the body, face, and ex- 
tremities. 

On t\ e fourth day, if you draw your finger across the surface, 

a well-defined line remains (sure sign). 
Eruption remains for five or six days, begmning to fade on 

the fourth day, and disappears on the sixth day, when 
There is a decrease in all the symptoms. 
Urine — scanty, suppressed, higli-colored and casts. 
Blueness of the finger ends (showing defective oxygenation 

of the blood). 

(Edema of the tonsils, uvula, and posterior walls of the 
pharynx, or ulcerative pharyngitis. 
Stage of Desquamation. 

Desquamation commences and the fever subsides. 

IRREGULARITIES. 

The most frequent are 

Overwhelming of the cerebro-spinal system, which shows 
itself in convulsions, stupor, delirium, restlessness, blue- 
ness of the finger ends, picking at the bed-clothes, etc. 

(Edema of the throat. 

Temperature — excessive, may rise to 107° or 108°. 
Pulse — greatly accelerated; mayreacli 140. 
Interference with tlie return circulation. 

Typhoid symptoms may occur from septic poisoning, and an 
ichorous discharge from tlie nose, indicating a slougliing 
pharyngitis (which is a very unfavorable sign). 



310 



DISEASES OF THE BLOOD. 



Ulcers of the mouth. 

Inflammation of the middle ear — producing delirium, intense 
pain, and rolling of the head (indicating acute meningitis). 
(Edema glottidis. 

COMPLICATIONS AND SEQUELS. 
Scarlatina nephritis may develop, resulting in anasarca about 
the time of convalescence, showing itself first on the face. This 
condition commencing with restlessness, nausea, vomiting, then 
pain in the head, anorexia, photophobia, insomnia, and elevated 
temperature, followed by stupor: the urine becomes scanty and 
high-colored, containing casts of the exudative variety, or blood 
casts and albumen, or epithelium, denoting inflammation of the 
uriniferous tubules, convulsions, coma, and death, may terminate 
the case. 

Other complications may occur, such as bronchitis; pneumonia; 
inflammation of the serous membranes; ulcerative endo-carditis; 
rheumatism; suppurative inflammation of the joints; diphtheria; 
suppuration of the middle ear; ursemia; and anasarca. 

CAUSES OF DEATH. 
Death may result from pyaemia; septicaemia; pneumonia; phthi- 
sis; or general anasarca, 

DIFFERENTIAL DIAGNOSIS. 
From measles; small-pox; erythema of surgical diseases; rose- 
ola, in this the anterior part of the pharynx is affected, and 
the symptoms are milder in character. In scarlet fever, the pos- 
terior part of the pharynx is affected. 

PROGNOSIS. 

Is uncertain. It depends upon the prevailing epidemics. 

If the symptoms of the eruption appear within forty-eight 
hours; if it reaches its minimum on the second day; if the throat 
symptoms are mild; if slight dysphagia and slight glandular en- 
largements exist; if the temperature be not higher than 104"; 
pulse, 120; if the cerebral symptoms are not severe or of long dura- 



SCARLET FEVER. 



311 



tion, and a steady decline of temperature occur, with disappear- 
ance of the eruption, the prognosis is favorable, even if slight 
nephritic symptoms have been present, as they will disappear in 
from four to six weeks. 

Should the temperature reach 105°, with extreme frequency of 
the pulse, dyspnoea, cold surface, small pulse, eruption of a livid 
hue, hemorrhage of the skin, suppurative pharyngitis (especially 
if extending to the nasal passages), copious coryza, nervousness, 
with typhoid symptoms, persistent vomiting, diarrhoea, nephritic 
symptoms, dropsy, complete suppression of urine, and the tem- 
perature inclined to rise, the prognosis is bad. 

Is bad, if occurring from infancy to five years of age; in preg. 
nancy; in organic diseases; or when complications exist. 

TREATMENT. 

Is both preventive and medicinal. 

Preventive. — Strict quarantine is absolutely necessary, and the 
same precautions relative to the sick-room as in typhoid fever. 
The patient should have plenty of fresh air and free ventilation. 
Every article that may carry the infection must be thoroughly 
disinfected. Frequent sponging and rubbing the body over with 
oil after each sponging will prove a great comfort to the patient • • 
during the period of desquamation. He must not he alloived to 
go out till desquamation is completed, wliich usually takes three 
weeks after desquamation has commenced. After recovery has 
taken place, the whole of the premises, and every article that has 
been in use, must be scrupulously disinfected. 

Medicinal.—YouY duty is to stand by and watch and guard 
against complications as they arise. The bedding and body linen 
should be frequently changed. A warm bath should be given 
once a day, and the body well washed with carbolized soap when 
desquamation sets in, as it aids desquamation, and the kidneys 
are thus relieved. Never allow the temperature to rise to 104° 
more than twenty-four hours witliout reducing it by cold sponge 
or tepid saline baths, and also administer large doses of qninine 
(see typhoid fever, page 270). Do not use the cold bath unless the 
temperature rise to 105°. 



312 ■ DISEASES OF THE BLOOD. 

« 

For throat complications. — In tlie early stage, give cold car- 
bonic acid water as a beverage, or allow ice to be held in the 
mouth. In the advanced stage, cloths wrung out in tepid or hot 
water may be apjDhed to the throat. Warm water gargles and in- 
halations may be used with great benefit at the same time. It is 
better to use hot rather than cold applications in every case; but, 
whichever plan is adopted, use either cold internally and externally, 
or hot internally and externally. Should there be ulcerations in 
the throat, spray them with carbolic acid, muriated tincture of 
iron, chlorate of potash, tannic acid, or any of that class of reme- 
dies. Should there be great pain, bromide of potassium or ether 
used in the same way will afford relief. Stimulants may be re- 
sorted to early should there be feeble heart's action. 

For kidney sequelce. — Dry or wet cups, followed by hot foment- 
ations, should be applied in the lumbar region, the temperature of 
the sick-room raised to 73°, and the same treatment adopted as in 
nephritis; or small doses of calomel may be given with a diuretic, 
and water shoidd be drank freely. Should convulsions occur, opium 
should be administered either hypodermically or by the mouth. In 
this disease, symptoms of Bright's disease are now detected by the 
sphygmograph, showing increased arterial tension and develop- 
4 ment of uraemia. 

MEASLES. 
MORBID ANATOMY. 
The blood is dark-colored, fluid, and poor in fibrin. The red 
corpuscles are diminished, and the white increased. There is a 
tendency to congestion of the internal organs. The liver and 
spleen are enlarged. There may be capillar}^ bronchitis and pneu- 
monia, which should be considered as part of the catarrhal affec- 
tion of the respiratory organs. The eruption at first is papular, 
showing especially on the chin and gradually extending over the 
body; it is of a bright-red color, sometimes shading off into blue, 
^ disappearing on pressure, and returning again immediatelj^ When 
the spots assume a dark-red color and do not disappear on pres- 
sure, capillary hemorrhages have taken place into the papules. 
The spots entirely disappear in from one to five days, leaving a 
yellow or brown stain behind which is due to pigmentation. 



MEASLES. 



313 



SYNOPSIS OF THE FOREGOING. 
The principal lesions are in the skin, organs, and blood. 
In the skin. — You have the eruption and a bran-like desquama- 
tion. There is catarrhal inflammation of the conjunctiva and 
mucous membrane of the resjiiratory passages; and there may 
be black or hemorrhagic spots on the skin. 
In the organs. — Some of the complications which are possible, 
such as capillary bronchitis, pneumonia, phthisis, gangrene, 
and abscess of the lung. Otorrhoea and effusion into the 
serous cavities may be present. 
In the blood. — All the common lesions of fevers (page 316) will exist. 
ETIOLOGY. 

It is a contagious and portable disease, and more easily con- 
tracted than small-pox or scarlet fever. The period of incubation 
is eight days. It may be induced by slight or prolonged exposure 
even with patients in the incubative stage. 

STAGES. 

Premonitory. Eruptive. And desquamative. 

SYMPTOMS. 

Premonitory stage. 
Coryza. 
Languor. 

ChiU (may be very indistinct). 
Convulsions in children. 
Eyes — suffused and red. 
Photoj)hobia. 

Sneezing and pain over the frontal sinuses. 
• Bronchial catarrh. 
Cough — dry, hoarse (iron cough). 

Fever and catarrh — which last about forty-eight hours. 
Eruptive stage. 

Eruption — from brigJd rose-red to mahogany, and, on fading, 
becomes yellowish-red ; appears first on the chin and face, 
then on the legs and arms, and lastly on tlie back of the 
hands; it takes four days to spread, and disappears about 
the sixth day. There are little red dots whicli are con- 
fluent, crescentic, and papillary, with swelling, itching, 
and a burning sensation. 



314 



DISEASES OF THE BLOOD. 



Desquamative stage. 

Desquamation — occurs in fine dust-like flakes. At this period 
the pulse is about 120 to 140, as a rule; the temperature 
usually about 103° (it rarely rises to 106°-107°). 

DIFFERENTIAL DIAGNOSIS. 

From scarlet fever and roseola. The catarrhal symptoms are 
the most prominent means of diagnosis in this disease. 

From typhus (in children) when the mucous membrane of the 
pharynx settles it; as it is more injected than in typhus. 

PROGNOSIS. 

If there be no complications, the prognosis is good. 

If dentition be progressing, it may render the prognosis bad. 

If the hemorrhagic ulceration be of the typhoid variety (black 
measles), the prognosis is grave. 

If it occur in pregnancy, or when there is profuse hemorrhage, 
the prognosis is bad; and in chronic diseases it is unfavorable. 

Death usually occurs in the second week. 

TREATMENT. 

The patient must be quarantined, and kept in a large, well- 
ventilated room at a temperature of about 63°-65^ F., and dark- 
ened so that the eyes may not be exposed to the light. The diet 
must consist of milk. Should there be itching and burning, 
sponge the body over with tepid water, as it aids in reducing the 
temperature. Convulsions may occur and cause death. Stimu- 
lants should never be used unless there be great prostration and 
bronchial affections. The utmost cleanliness must be observed. 
If the temperature rise to 103°-104'' it must be reduced by tepid or 
cold sponging, and quinine. If the thirst be great, cold water 
may be given in small quantities as a beverage. If posterior 
pharyngeal catarrh, capillary bronchitis, or croupous laryngitis oc- 
cur, inhalations of steam will be found very beneficial in relieving 
the symptoms. Should there be catarrhal pneumonia, stimulants 
must be given with judgment. If pulmonary complications arise, 
the patient must be protected from exposure. If there be groat 
restlessness, give pulv. Doveri (small). If typhoid or hemorrhagic 
symptoms occur, use stimulants early. 



KOTHELN. 



3J5 



KOTHELN. 

This disease may be confounded with measles and scarlet fever. 
STAGES. 

Invasion. Eruption. Desquamation. 

SYMPTOMS. 

Stage of Invasion. \ 
Shivering. 

Nausea and vomiting. 
Sore throat. 
Weakness. 

Premonitory fever — which is short, and relieved when the 
eruption appears. 
Stage of Eruption. 

Eruption — appears simultaneously over the whole body; is 
sudden, less marked on the limbs than on the trunk, and 
fades in about four days without desquamation. On the 
first day, the eruption is like measles (minute dots); on the 
second day, irri3gular patches occur, varying from the size 
of a three-penny piece to that of a shilhng; and on the 
third day, these are elevated and dark-red in the centre. 

Temperature — is highest on the first day, never exceeding 
102°; it falls on the second day to 100"; and on the fifth 
days becomes iiormal. 
Stage of Desquamation. 

Desquamation only occurs in rare cases; it resembles bran, 
and commences in the centre of the patch. 

SEQUELJE. 

Swelling of the lymphatic glands; in rare cases, suj)puration and 
dropsy. 

PROGNOSIS. 

Is favorable. 

TREATMENT. 

Avoid exposure to cold draughts of air, and protect the body 
with flannel. The medicinal treatment must be indicated by the 
symptoms which are most prominent. 



TABLE OF DIFFEEENTIAL DIAQNOSIS BETWEEN 



TYPHUS. 



CONTAGION. 

Is contagious, infectious, 
portable. 



and not 



hospital; 
cerebral 
and con- 



SYNONYMS. 
Ship ; jail ; camp ; putrid ; 
fourteen day; petechial; 
typhus ; exanthematous 
tinned fever. 



MORBID ANATOMY. 

The principal changes will be found 
in the skin, organs, and blood. 

Skin, — Mulberry rash present on the 
sides of the chest and abdomen, and 
possibly on the extremities. It dis- 
appears on pressure (for three days), 
and the penumbra is dark in color 
and somewhat elevated. 

Brain. — Hypersemia of the vessels of 
the convexity. Meningeal exuda- 
tions. Serous effusion of the pia 
mater and into the ventricles. The 
arachnoid is opaque and dotted 
with yellowish spots. 

Alimentary Canal.— The changes 
are principally confined to Beyer's 
patches and the solitary glands 
which are found to be congested, 
and to have the "shaven beard" 
appearance. 

The evidences of complications are: 
bronchitis, pneumonia, spleniza- 
tion, pleurisy, oedema, meningitis, 
parenchymatous nephritis, ulcera- 
tion of the larynx, pharynx, and 
mouth, and enlarged cervical glands 

*Blood. — Common lesions. 



TYPHOID. 



CONTAGION. 

Is non-contagious, but infectious. It 
requires prolonged exposure, gain- 
ing access to the body, through tlie 
air we breathe and the water we 
drink, thus becoming contagious. 

SYNONYMS. 
Autumnal; abdominal typhus; en- 
teric; gastro-enteric ; gastric: forty 
day ; dotlientherica ; ilio-typhus ; 
and typhoid afiiection of Louis. 

MORBID ANATOMY. 

The changes are confined to the skin, 
organs, and blood. 

Skin, — The eruption is confined to 
the abdomen, but it may ap])ear on 
the chest, consisting of crops last- 
ing three days each; they are few 
in number, slightly elevated, and 
called the rose rash. 

Organs. — The pathognomonic lesion 
is confined to Peyer s patches, the 
solitary and mesenteric glands, 
which undergo the following 
changes: 

1. Congestion and the "shaven-beard" 
appearance. 

2. Hyperplasia and hardening. 

3. Softening of the glands from fatty 
degeneration. 

4. Absorption or rupture of glands 
and evacuation of contents through 
sloughing or suppuration; Avhich 
may result in perforation or forma- 
tion of typhoid ulcers. The ulcer 
] laving its long axis parallel to tlie 
long axis of the intestine, 

5. Cicatrices, etc., may forin. 

Brain. — Hyperemia of vessels, (ede- 
ma, and i)uiictate extravasations 
and appearance. 

The evidences of complications are 
intestinal luMuorrhage, peritonitis 
from perforation, pneumonia, par- 
enchymatous nephritis, spleniza- 
iion of the lung, and catarrhal in- 
llanimation of tlie bronchi. 

*Blood. — Conmion lesions. 



*N. B. — There are certain lesions common to all levers - such as decrease in 
blood-corpuscles; staining of tlie>'surrouiiding list^ue;? with hiematin; soften- 

316 



THE FIVE PEmCIPAL EEUPTIVE FEYEES. 



SCARLET. 

CONTAGION. 

Is contagious, infectious, 
and portable. 

SYNONYMS. 
Scarlatina simplex; scar- 
latina anginosa: scar- 
latina maligna, and red 
rash. 

MORBID ANATOMY. 
The changes are confined 
to the skin, mucous 
membranes, organs, 
and blood. 
■ Skin. — There are evi- 
dences of a peely des- 
quamation, local ab- 
scesses, and character- 
istic eruption before 
death. 

Mucous Membrane. — 
Suppuration in the vi- 
cinity of the throat; ul- 
ceration of the tonsils. 
Eustachian tube, mid- 
dle ear, and possibly of 
the cornete. 

Organs. — Desquamative 
nephritis, and some of 
the i)ossible complica- 
tions, as pneumonia, 
pleurisy, peri-card itis, 
endo-carditis, and ne- 
crosis of the middle 
ear. 

*Blood. — Common le- 
sions. 



MEASLES. 



CONTAGION. 

Is contagious, infectious, 
and portable. 



SYNONYMS. 
Rubeola. 



MORBID ANATOMY. 

The changes are in the 
skin, organs and blood. 

Skin. — There will be the 
characteristic eruption 
and hran-like desqua- 
mation ; catarrhal in- 
flammation of the con- 
junctiva, and mucous 
membrane of the res- 
piratory passages, and 
black or hemorrhagic 
measles on the skin. 

Organs. — Some of the 
complications possible, 
as capillary bronchitis, 
pneumonia, phthisis, 
gangrene, otorrhoea, 
abscess, and efi'usion in 
the serous cavities. 

"Blood. — Common le- 
sions. 



SMALL-POX. 



CONTAGION. 

Is contagious, infectious, 
and portable. 



SYNONYMS. 
Variola discreta; variola 
confluens; variola hem- 
orrhagica, and vario- 
loid. 

MORBID ANATOMY. 
The changes are in the 
skin, mucous mem- 
branes, organs, and 
blood. 

Skin. — All the stages of 
eruption which may be 
macule, papule, vesi- 
cle, pustule, scab, or 
cicatrix; also, possible 
abscess, ulceration and 
local slough. 

Mucous Membrane. — 
Within the urethra, 
eye, nose, mouth, and 
middle ear, the same 
conditions are possible. 

Organs. — Parenchyma- 
tous nephritis, oedema 
glottidis. Evidences of 
complication, as pleu- 
risy, pneumonia, peri- 
carditis, endo-carditis, 
meningitis, bronchitis, 
and fluid blood, may be 
found in some of the 
serous cavities. 

*Blood. — Common le- 
sions. 



the fibrin and albumen of the blood, disorganization and serration of the red 
ing of tlie mucous membrane of the alimentary canal and the various organs. 

317 



TABLE OF DIFFEEENTIAL DIAGNOSIS BETWEEN 



TYPHUS. 



ETIOLOGY. 

Is epidemic, and produced by some 
animal poison arising from human 
effluvia; from overcrowding, and 
filth; is communicable by direct 
contact. 



STAGES. 
Incubation, invasion, and eruption. 



ADVENT. 

Suddenly, with intense chill and 
marked symptoms, and steady in- 
creasing headache, delirium and 
great prostration. 



DURATION. 

Fourteen days. 

CRISIS. 

On twelfth day, accompanied by a 
sudden termination of sj^mptoms 
and a healthy sleep. 

TEMPERATURE. 

Very high; on the second day 104°; 
frequently 105° to 107°, about third 
day; remains so till convalescence. 
Is a higher temperature than any 
other affection but sunstroke and 
bilious remittent and relapsing 
fever. 

PULSE. 

First week about 110 to 120. 

Second week generally 100, frequent, 

soft, rapid, and easily compressible. 

It may be irregular. 



TYPHOID. 



ETIOLOGY. 

Is endemic, and due to decomposing 
organic matter, mixed with ty- 
phoid material. 



STAGES. 
Incubation, invasion, and eruption. 



ADVENT. 

Insidiously, with general malaise, 
vomiting, headache, photophobia: 
cliill is rare; five days elapse be- 
fore patient takes to his bed. 



DURATION. 

Twenty-one to forty days. 

CRISIS. 

None. Tympanites gradually disap- 
pearing, and the tongue gradually 
clearing. 

TEMPERATURE. 

Very little increased at onset. 

Is exacerbating, seldom above 104' or 
105°, and reaches its maximum 
about the seventh day: begins to 
fall al)Out the end of third week, 
and becomes normal at the end of 
the fourth week. 

PULSE. 

During first week 98 to 110. 

In second week falls, or may even rise 

to 140. 
Third week is variable. 
Fourth week falls to about normal. 



318 



THE FIVE PEINOIPAL ERUPTIVE FEVERS. 



SCARLET. 



ETIOLOGY. 

Contagion direct and by 
the clothes . It m ay go 
through a whole fam- 
ily. Is most infectious 
at the time of desqua- 
mation. 



STAGES. 

Incubation, invasion, 
eruption, and desqua- 
mation. 

ADVENT. 

Period of incubation is 
from two to ten days, 
but generally four to 
seven. Commences in 
children with head- 
ache, vomiting, gen- 
eral malaise, rash, and 
sore throat. 

DURATION. 

Twenty-one to twenty- 
eight days. 

CRISIS. 

About the fourteenth 
day. (?) 

TEMPERATURE. 

May reach 105'^ or 107 '; 
is higher during the 
eruption, and begins to 
subside about the tenth 
day. It has no second- 
ary fever. 

PULSE. 

Accelerated ; may even 
reach 140. 



MEASLES. 



ETIOLOGY. 

Is a portable disease, and 
more tenacious than 
scarlet fever and small- 
pox. 



STAGES. 

Premonitory or precur- 
sory; eruptive and des- 
quamative. 

ADVENT. 

Period of incubation is 
eight days. 

Commences with chill, 
coryza, frontal head- 
ache, lassitude, harsh 
cough and fever, which 
usually lasts about for- 
ty-eight hours. 

DURATION. 

Fourteen to twenty- one 
days. 

CRISIS. 

None. 

TEMPERATURE. 

May reacli 105°, and sinks 
to normal twenty-four 
hours after ap]^earance 
of the rash. It has no 
secondary fever. 



PULSE. 
Slightly accelerated. 



SMALL-POX. 



ETIOLOGY. 

Is propagated by conta- 
gion; by the breath and 
exhalations from the 
skin (at two and a half 
feet distant in the open 
air) ; can be conveyed 
by clothing, etc., and 
attack all ages. 
Is more infectious during 
the stage of suppura- 
tion or diminution, or 
even incubation. 

STAGES. 

Incubation ; invasion ; 
eruption ; suppuration; 
desiccation. 

ADVENT. 

Period of incubation is 
from ten to thirteen 
days. If from inocu- 
lation (48 hours). It 
commences with an 
initiatory stage of chil- 
liness, severe pain in 
the back, loins, head, 
and nausea, etc. 

DURATION. 
Four to five weeks. 

CRISIS. 
About twenty-first day. 
(?) 

TEMPERATURE. 

Is often 106' at onset, 
and may reach 109". 
After eruption appears, 
it usually falls to 100^ 

Secondary fever very 
high on the eighth day, 
and falls slowly. 

PULSE. 

May rise from 100 to 120, 
or even 140. 



319 



TABLE OF DIFFEKENTIAL DIAGNOSIS BETWEEN 



TYPHUS. 



ERUPTION. 

Small, irregular-shaped, brick dust 
spots, slightly elevated at first, 
called the '' mulberry ?'a.s7i." Re- 
mains throughout the disease. Ap- 
pears on the fifth to the seventh 
day of the fever, and disappears on 
pressure for the first two days of 
the eruption. Appears chiefly on 
the sides of the chest and extremi- 
ties. 



CEREBRAL SYMPTOMS. 
Active delirium and terrific head- 
ache from the onset. 



CONDITION OF THE PUPILS. 
Contracted. 



EPISTAXIS. 
Rare, and of no importance. 

CONDITION OF TONGUE. 
First, swollen and white-coated; after 
a day or two, becomes of a yellow- 
ish-brown color and thick; later 
on, dark, drv, and fissured. 



COUNTENANCE. 
Dull and heavy, and later on of a 
mahogany color (drunken face).' 



DESQUAMATION. 



None. 



TYPHOID. 



ERUPTION. 

Lenticular spots, slightly elevated. 
Bright rose color. 

Appears in successive crops (each 
crop lasting three days), and disap- 
pears, when another crop takes 
their place. It disappears on the 
slightest pressure, and reappears 
instantly. Appears on tlie abdomen 
chiefly about the seventh day. 



CEREBRAL SYMPTOMS. 
Are not present till about the second 
or third week, and appear as a 
muttering delirium. 



CONDITION OF THE PUPILS. 
Dilated. 

EPISTAXIS. 
A frequent and grave S3-mptom, if 
appearing late in the disease. 

CONDITION OF TONGUE. 
Is first of a light wliite color; then 
red on the tip and sides, and dry in 
in the centre; then heavily coated 
with S(^rdeson tlieteetli and mouth, 
and, after a time, becomes clear 
and shining, like beef. 

COUNTENANCE. 
Pale, olire. or leaden look. 



DESQUAMATION, 



None. 



320 



THE FIVE PEINCIPAL EEUPTIVE FEVEES. 



SCARLET. 



ERUPTION. 

Appears 24 hours after 
the fever of invasion. 

If the attack be mild, the 
color is bright rose; but 
if severe, it will be a 
deep-red lobster color. 
If the fingernail be 

. drawn over the erup- 
tion, a Avhite line will 
remain, which will last 
for two or three min- 
utes. 

It appears first on the 
neck, and spreads rap- 
idly. 



CEREBRAL SYMP- 
TOMS. 
Frequent and grave. 



CONDITION OF THE 

PUPILS. 
May be contracted. 

EPISTAXIS. 
Absent. 

CONDITION OF THE 

TONGUE. 
"Strawberry" to.igue. 



COUNTENANCE. 
Flushed, dry, and red, 
and headache. 

DESQUAMATION. 
Occurs in large y)atclies, 
esijecially from tlie 
hands and feet, with 
itching, and successive 
desquamation (peely) 
may occur. 



MEASLES. 



ERUPTION. 

It appears on the fourth 
day as little dots, like 
flea bites, of a rose-red 
or mahogany color. 
May be confluent, cre- 
scentic, and papular. 
If the fingernail be 
drawn over the erup- 
tion, a line appears, 
which disappears as 
quickly as the pressure 
is removed. 

It appears first on the 
face, round the mouth, 
and on the neck, then 
on the legs and arms, 
and lastly, on the back 
of theliands. 

CEREBRAL SYMP- 
TOMS. 
Usually absent. 



CONDITION OF TELE 

PUPILS. 
Normal. 

EPISTAXIS. 
Absent. 

CONDITION OF THE 

TONGUE. 
Coated, and red on the 

edges. Throat is sore ; 

coryza; and bronchitis. 



COUNTENANCE. 
Suffusion and redness of 
the eyes, and coryza. 

DESQUAMATION. 
Is b);in-like, ;uid has an 
odor of mouldy cheese 
{mealy). 



32X 



SMALL-POX. 



ERUPTION. 

Appears about the third 
or fourth day. 

1st. As a macule. 

3d. Papiile. 

3d. Vesicle. 

4th. Vesicle becomes um- 
bilicated. 

5th. Vesicle changes col- 
or, and becomes a 
pustule, which may 
slough, and result in 
cicatrix and pitting; or 

6th. Scab. 

It appears first at the root 
of the hair, lips, palate 
or fauces. 



CEREBRAL SYMP- 
TOMS. 
Frequent; delirium prob- 
able about the third 
day. 

Convulsions in chilt'- en. 
CONDITION OF THE 

PUPILS. 
May be contracted. 

EPISTAXIS. 
Infrequent. 

CONDITION OF THE 
TONGUE. 

Coated and swollen, and 
red on the edges. Sore 
throat and dry cough. 



COUNTENANCE. 
Anxious and flushed ; pho- 
tophobia and headache. 

DESQUAMATION. 
Scabs, crusts, and tliick 
scales in large quanti- 
ties, with intolerable 
itching (scaly). 



TABLE OF DIFFEEENTIAL DIAGNOSIS BETWEEN 



TYPHTTS 


TYPHOID 


EMACIATION. 


EMACIATION. 


Slight. 


Great. 


CONDITION OF THE BOWELS. 


CONDITION OF THE BOWELS. 


Constipated; no tympanites nor ten- 
derness. 


Diarrhoea (pea soup). 

Tympanites. — This is a bad sign; it 

indicates gas in the intestines. 
Pain and gurgling in the right iliac 

fossa. 


INTESTINAL HEMORRHAGE. 


INTESTINAL HEMORRHAGE. 


Rare. 


Frecxuent. 


CHANGES IN URINE. 


CHANGES IN URINE. 


Is first diminished, then increased; 

and suppression may occur later on 

in the disease. 
There are vesical, renal, and fatty 

casts; and albumen and urea are 

increased. 


Increased in quantity. 
No albumen; casts are rare. 
Urea is diminished at first, and in- 
creased later on. 


COMPLICATIONS. 


COMPLICATIONS. 


Subacute meningitis ; pulmonary 
gangrene ; capillary bronchitis ; 
pneumonia ; pleurisy ; congestion ; 
oedema; laryngitis; and Bright's. 


Peritonitis; abscesses; pleurisy, with 
pus exudation; simple bronchitis; 
catarrhal pneumonia. 


SEQUELJE. 

None. 


SEQUELS. 

None. 


CAUSES OF DEATH. 


CAUSES OF DEATH. 


Coma; syncope; capillary bronchitis; 
gangrene of the lung; meningitis; 
pneumonia; exhaustion, from the 
effects of the poison; Bright's gran - 
ular kidney. 

35 


Toxaemia; debilitj-; suppression of the 
excretory function of the kidne}-; 
hyperaimia and oedema of the 
lungs; intestinal hemorrhage; ex- 
haustive diarrhoea; intestinal per- 
foration ; peritonitis, with or with- 
out perforation; relapse from ab- 
sorption of the poison; cathartics, if 
given during the first week. 



THE FIVE PEINCIPAL EEUPTIVE FEVEES. 



SCARLET. 



EMACIATION. 
Slight. 

CONDITION OF THE 

BOWELS. 
Not specially affected. 



INTESTINAL HEMOR- 
RHAGE. 

Absent. 

CHANGES IN URINE. 

In the latter stages, urine 
becomes scanty, high- 
colored; contains casts, 
as epitljielial, small hy- 
aline, blood, and blood - 
globules ; indicating the 
inflammatory stage of 
parenchymatous ne- 
phritis. 

COMPLICATIONS. 

Pleurisy (frequent) ; bron- 
chitis; pneumonia (in 
rare cases); inflamma- 
mation of serous mem- 
branes ; oedema glot- 
tidis; ulcerative endo- 
carditis and diphtheria. 



SEQUELS. 
Bright's ; dropsy ; deaf- 
ness; conjunctivitis ; 
phthisis; chronic diar- 
rhfrn; and glandular 
enlargements. 

CAUSES OF DEATH. 



MEASLES. 



EMACIATION. 
Not marked. 

CONDITION OF THE 

BOWELS. 
Not specially affected. 



INTESTINAL HEMOR- 
RHAGE. 

Absent. 

CHANGES IN URINE. 
None. 



COMPLICATIONS. 

Pneumonia (frequent); lo- 
bar pneumonia; phthi- 
sis; ophthalmia; capil- 
lary bronchitis; abscess 
of the lung; gangrene 
of the lung ; Bright's ; 
gastric catarrh; profuse 
hemorrhage. 

SEQUELS. 
Chronic bronchitis; con- 
junctivitis ; phthisis ; 
otorrhoea. 



CAUSES OF DEATH. 



SMALL-POX. 



EMACIATION. 
Great. 

CONDITION OF THE 
BOWELS. 

Not specially affected., 



INTESTINAL HEMOR- 
RHAGE. 

Absent. 

CHANGES IN URINE. 

May be scanty and high- 
colored, and contain 
casts at the commence- 
ment of the stage of 
suppuration ; indicat- 
ing the first stage of 
parenchymatous ne- 
13hritis. 

COMPLICATIONS. 

Pneumonia (in rare cases); 
bronchitis ( general) ; 
oedema glottidis. 



SEQUELS. 
Chronic diarrhoea ; ab- 
scesses; glandular en- 
largements ; various 
diseases of the eyeball 
and eyelid. 

CAUSES OF DEATH. 

Oedema glottidis; gene- 
ral bronchitis; pneu- 
monia; pyaimia; serous 
inflammation of the 
brain and heart. 

Acute fatty degeneration 
of the kidn'iy. 



Convulsions, from exces- 
sive blood-poison ; bron- 
chitis; pneumonia; py- 
aemia; diphtheria; sep- 
ticaemia; phthisis; gen- 
eral anasarca ; and 
Bright's. 



Any of the above com- 
jdications, especially 
capillary bronchitis in 
children, and phthisis 
in the adult. 



323 



324 



DISEASES OF THE BLOOD. 



mFAECTIONS. 
DEFINITION. 

Are wedge-shaped spots of discoloration and consolidation in an 
organ; dependent upon capillary obstruction and collateral hyper- 
semia. Their base usually looks toward the periphery of the 
organ in which it occurs, and the apex toward the centre. 

VARIETIES, 

1st. Thromhic — in which the veins, where the seat of stoppage 
occurs, are distended and engorged. Tlie obstruction, in this 
form, is dependent upon a mechanical or inflammatory stasis. 

If a vein be plugged by a tlirombus, the arteries rupture from 
collateral circulation. 

2d. Embolic — the obstruction usually takes place in the arteries- 
A clot is first formed in a vein, and passing onward to the heart, 
is forced into the lung, or other organs, and plugs some artery of 
those organs. It may be due to a vegetation from the valves of 
the right heart. 

If an artery be plugged by an embolus, the veins usually rup- 
ture from collateral circulation. 

3d. Pycemic — which may be either one of the above-named 
varieties, for explanation see pages 326 and 327. This type of in- 
farction usually suppurates; as the obstruction in the vessels, if 
due to thrombosis, depends on a poisoned condition of the blood; 
while, if due to an embolus, it depends upon a suppurative phle- 
bitis of some point more or less remote from the lungs, which has 
caused a disintegration of a blood-clot (thus causing emboli). 

SEPTICEMIA. 
DEFINITION. 

Is a blood-condition dependent upon absorption of decomposing 
animal matter by the lymphatics, when placed in actual contact 



SEPTICEMIA. 



325 



with a living membrane (example — decomposing placenta in the 
uterus). 

MORBID ANATOMY. 

The severity of the disease depends upon the amount of poison 
absorbed . It is a disease that may iDroduce death in twenty-four 
hours if a large quantity of the poison has been introduced into the 
system, or it inay become a continued fever when small quantities 
are gradually introduced. It may be recovered from, in some cases, 
by arresting tlie development of the x^oison, or by the removal of 
the cause. The princiiml lesion in this disease occurs in the blood 
which will be found to lose its normal power of coagulating, is 
darker than normal, and undergoes decomposition when drawn 
from the body; but should coagulation take place, the coagula 
will be found to break down A-ery easily. On post-mortem ex- 
amination, the liver will usually be found congested and oedema- 
tous; the spleen and mucous membranes softened; the salivarj^ 
glands enlarged; and the muscles of the heart weakened. 

ETIOLOGY. 

It can only occur when decomposing animal matter is brought 
into direct contact with the living membrane. It occurs in gan- 
gi'ene and abscess of the lung; suppurative endocarditis; retained 
placenta; dead foetus in utero; post-mortem wounds; diphtheria; 
introduction of sulphuret of ammonia into the system; decompos- 
ing urine in the bladder; typhoid ulcers, etc. 

SYMPTOMS. 
Chill— but not distinct (rather rigors). 
Sudden fever. 

Temperature — (depends upon the amount of poison absorbed) in 

mild cases, 102"-103^; in severe cases, 105°-107°. 
Pulse— may rise to 120 or 140. 
Stupor— the patient answers questions stupidly. 
Profuse perspiration. 

Dinginess and dryness of the surface (following the profuse per- 
spiration). 
Typhoid symptoms. 



326 DISEASES OF THE BLOOD. 

Jactitations. 

Delirium — low muttering; the patient probably i)asses on to coma. 
Diarrhoea — profuse watery (is an effort of elimination on the part 
of Nature). 

DIFFERENTIAL DIAGNOSIS. 
From pyaemia — from which it differs in not resulting in meta- 
static abscesses; although there are chills, still they are not re- 
current as in pyaemia. 

PROGNOSIS. 

Depends upon the amount of poison present in the system. It 
is fatal when the poison is intense. 

TREATMENT. 
Same as in pyaemia (see page 329). 

PYEMIA. 
DEFINITION. 

Is produced by a miasm, generated by decomposing pus, and 
characterized during life by chills (recurring), fevers, and sweats, 
and, after death, by metastatic abscesses all over the body. 

MORBID ANATOMY. . 
There is a peculiar jaundiced appearance to the skin, which is 
characteristic of the disease. The blood, as a result of the 
miasmatic infection, exhibits a tendency to coagulate spontane- 
ously, especially where the current is slowed, as in the capillary 
vessels. Fine coagula will be found in the heart, also an inter- 
lacing of the chordae tendineae. In the various organs through- 
out the body, tliere will be infarctions, which result in abscesses. 
The mucous membranes of the body will be found to be tiiickened. 

ETIOLOGY. 

It is often due to a suppurativo capillary plilebitis. occurring in 
persons suffering from disordered or low conditions of the blood. 
It may be either local or general; should it be local, the symi)toins 



PYEMIA. " 



327 



will be rapid, but if general, it will take some time before thor- 
ough development of the symptoms takes place. It may occur 
in either closed or open wounds in the following manner: 

In closed wounds— (!) from a blow (say on the head); (2) phlebitis 
of the diploe ensues; (3) a clot is formed in the veins at the seat 
of the injury; (4) suppuration of the clot and breaking down of 
the same takes place (this causes loosening of the clot, whose 
particles jmss through the large blood-vessels to the heart, and 
thence to the lungs), resulting in (5) an embolus of the lung or 
other organs, which causes (6) an infarction. This condition is evi- 
denced by a wedge-shaped spot of discoloration and consolidation, 
dependent on capillary obstruction and collateral hyperaemia; its 
base usually looks toward the peripliery of the organ, and its apex 
toward the centre. The embolus having been a poisoned one, 
since it was due to unhealthy suppuration, the infarction under- 
goes a similar suppuration ; its coagula break down and multiply 
emboli in the blood, which are carried througli tlie left heart into 
the general circulation. It is in this manner that metastatic ab- 
scesses are formed all over the body, since these emboli become 
lodged in other organs, and then generate infarctions which 
again suppurate. 

In open wounds. — Pyaemia is due (1) to some miasmatic atmo- 
spheric conditions (probably generated in decomposing pus); (2) 
the miasm is probably absorbed by the blood-vessels, and not by 
the lymphatics; (3) the effect of the miasm is shown by a ten- 
dency in the infected blood to coagidate spontaneously in the 
small capillary vessels where the current is slow; (4) the small 
coagula thus formed (thrombi) in different parts of the body cre- 
ate suppurative and metastatic abscesses, on account of their 
poisoned character. The duration of the disease is from eight to 
ten days, or it may even extend to three weeks. 

SYMPTOMS. 
Initial symptoms — are usually well marked. 

Chills— which are sharp, long, and recur at intervals for several 
days. 

Profuse sweating — which follows every chill. 



328 



DISEASES OF THE BLOOD. 



Temperature — rises before the chill occurs to 104° or 105°. Tliis 
rise either precedes or accompanies the chill, and also the 
perspiring stage; but, after the perspiring stage, the temper- 
ature may even become normal, as occurs in the puerperal 
type, or it may have a marked rise. 107". 

Pulse— rapid (140 to 200), small, feeble, and rarely irregular. 

Restlessness. 

Delirium — which will be of a low and muttering character. 
Cellulitis — esx^ecially in the glands with loss of vitalit}^ of adjacent 

tissues and subsequent suppuration. 
Exhaustion — extreme. 

Jaundice — (of the hematogenous variety) due to the changes in 
the red globules of the blood from the action of the pya?mic 
poison, or to the action of the poison on the nerve-centres. 

Respiration — hurried, especially just before a chill or sweat. 

Breath — has a sweet, nauseating odor. 

Perspiration — has a sweet, nauseating odor, staining the clothing 

to a dirty yellow color. 
Urine— is at first scanty and liigli-colored, then becomes more 

abundant; the high color is due to changes in the coloring of 

the blood. 
Dian-hoea — ^profuse watery. 
Cough. 

Expectoration — sometimes streaked with blood, or may oe pneu- 
monic. 

Emaciation and feebleness. 

Tongue— is at first glairy, and subsequently heavily coated with 
sordes, and further sjanptoms of a typhoid variety ensue. 
PIFFERENTIAL DIAGNOSIS. 
Is easily made. It may be confounded with some of the in- 
fectious fevers as septicaemia: but, in this latter case, you rarely 
have a second cliill, and. if you do. it always follows the fever. 
There is also the peculiar hue to the skin to enable the diagiiosis 
of pyaemia to be made. It may also be mistaken for acute artic- 
ular rheumatism, or for those cases of scarlet fever when sup- 
puration occurs. 

PROGNOSIS. 
Is worse than in almost any other disease. 



ERYSIPELAS. 



329 



TREATMENT. 

The prophylactic treatment will only interest the surgeon, and 
also the physician, during the puerperal stage. When there is an 
unhealthy suppuration, antisej)tic treatment will tend somewhat to 
stop it. Of all the curative remedies, fresh air stands first to over- 
come these diseases. Let the patients be placed in tents or pavilions, 
where they will have as free ventilation as in tents, and use all 
the means of disinfection. Diaphoretics and diuretics have been 
advised, but it was found that the patients went much more 
quickly into a state of collapse than when they were left alone. 
Sulphurous acid has been advised, but this was so difficult to ad- 
minister, that sidphites (gr. xx.-xxx. doses) of sodium, calcium, 
and magnesium were administered, as they were claimed to neu- 
tralize the poison, but this treatment was not found by clinical 
experience to have the desired effect. Quinine has been suggested 
on account of its having such a wonderful effect in malarial 
diseases, and this, like its predecessors, has been found to be of no 
avail, and has also been abandoned. Stinadants should be ad- 
ministered early and in large quantities, and so keep up the 
patient's strength as much as possible. Opium should be given 
hypodermically to quiet the restlessness that occurs prior to the 
chills and sweatings. The patient's body, bed, and linen should 
be kept scrupulously clean. The diarrhoea and perspiration 
should not be checked. Good nursing is indispensable, and con- 
centrated liquid food, as milk with lime-water, eggs, beef -tea, at 
short intervals. 

ERYSIPELAS. 
DEFINITION. 

Is a diffuse erythematous inflammation of the skin or the mucous 
and serous membranes, which rapidly spreads, and is attended 
with febrile symptoms. It is both contagious and infectious. 

VARIETIES. 

(1) Cutaneous or simple; (3) phlegmonous; and (3) internal. 



33G 



DISEASES OF THE BLOOD. 



Cutaneous variety — attacks the superficial portion of the skin. 

Phlegmonous variety —attacks the sub-cutaneous areolar tissue, 
as well as the cutaneous surfaces. 

Internal variety — where the serous and mucous membranes are 
involved, producing cellulitis, also involving the fasciae, aponeu- 
roses, etc., etc. 

ETIOLOGY. 

Predisposing causes. — Bad hygiene; filth; deprivation of food, 
etc.; over-fatigue; over-anxiety; intemperance; sedentary habits; 
indolent life; high living; diabetes; albuminuria; drinking bad 
water, etc. 

Exciting causes.— Change of temperature; cold or damp air; 
wounds. 

SYMPTOMS. 

Cutaneous variety. 

Face — chiefly affected (which becomes red, oedematous, and 

distorted). 
Chill. 

Temperature — rises to 103°-104°. 

Nausea. 

Vomiting. 

Stupor. 

Eyes — closed by swelling and oedema. 
Delirium. 

Typhoid symptoms — which abate in about eight to twelve 
days. 

Skin — grows pale, scaly; abscesses or boils may form. 
The beard falls out and frequently returns. 
This variety also occurs from wounds in the head. 
* Phlegmonous variety. 

Skin — over the affected portion becomes tense, shining, and 
subsequently sloughs, and exhaustive suppuration ensues. 
Duration depends upon the severity of the attack. 

DIFFERENTIAL DIAGNOSIS. 
From phlebitis — wliich gives the feeling of a hard cord running 



ERYSIPELAS. 



331 



across the inflamed part. It attacks the walls of the veins in- 
stead of the tissues and lymphatics, as in erysipelas. 

PROGNOSIS. 

The cutaneous or simple variety generally gets well, but it may 
attack some other organ, as the lungs, peritoneum, or pelvis, or 
even the brain. In the strong and healthy, the duration is from 
seven to fifteen days; the first four days it usually tends to spread; 
the second four days it gradually clears up, and it takes two days 
more to get well. 

In the phlegmonous variety, the prognosis is unfavorable, as 
you have suppuration; and especially unfavorable if occurring 
in young children, and those addicted to intemperance and bad 
living. 

TREATMENT. 
Is both preventive and curative. 

Preventive. —First remove all obstacles. Keep the patient in 
bed in a large, well-ventilated room; perfect cleanliness must be 
observed. The diet should be nutritious, and stimulants avoided, 
if possible. 

Curative. — This is divided into constitutional and local treat- 
ment. 

Constitutional. — Be on your guard against fever. The patients 
must be supported in moderation, should there be any signs of an 
asthenic (debilitating) fever, by giving stimulants, such as milk 
punches, egg-nog, port wine (by the bottle), strong beef -tea, bark, 
ammonia, etc. Large doses of tr. ferri mur., gtt. xv.- 3 ss. every 
two or three hours day and night. 

Local. — In the simple form tliQ inflamed parts should be painted 
over with butter-milk; it cools and protects them from the air, or 
bathe the parts with the following lotion: j^lumbi acet., 3i.; 
opii, 3 ss. ; aqua3, O.i. ; or a lotion made of ipecac and water. Do 
not use iodine, as it only irritates the parts, nor nitrate of silver, 
as it is of no service. 

In phlegmonous form. — Incisions should be freely resorted to. 
Do not be afraid of free incisions, as it greatly relieves the patient; 
afterward poultice the part with linseed meal. Keep the limb 



332 



DISEASES OF THE BLOOI>. 



well covered over with cotton wool, and so soon as the discharge 
is well carried away, and the parts assume a healthy appearance, 
commence the process of healing by strapping. 



EHEUMATISM. 

Is a disease dependent upon a morbid condition of the blood, 
due to a poison (probably lactic acid), which is developed within 
the body, having the power of rendering the secretions and ex- 
cretions acid, and associated with an alteration in the various 
salts, favoring an increase in the fibrin of the blood. 

VARIETIES. 

Acute and chronic articular; deforming articular; muscidar; 
and gonorrheal. 

ACUTE ARTICULAR RHEUMATISM. 
SYNONYM. 

"Flying gout." 

DEFINITION. 

Is an inflammatory disturbance of nutrition, located in the 
synovial capsule of one or more of the joints of the body. 

MORBID ANATOMY. 
On post-mortem examination, the synovial capsule of the 
affected joints may be found to be of a dark-red color (due to hy- 
pera3mia or ecchymosis); it will also be relaxed and puffed up, and 
the joint dilated and filled with purulent fluid. The blood in the 
heart and large blood-vessels shows large deposits of fibrin. 
Heart lesions are frequently developed in the course of this 
disease. 

ETIOLOGY. 

It is a disease which occurs principally among the poorer classes 
(as in fishermen, etc.). It usually occurs between the ages of lif- 



ACUTE ARTICULAR RHEUMATISM. 



333 



teen and forty years, from possibly an hereditary tendency, the 
mode of life, or a faulty digestive process. Its exciting causes 
are exposure to cold, by suddenly wetting the heated body; by 
exposure to a draught; or living in damp places. The duration 
of the disease is usually from two to six weeks. 

SYMPTOMS. 
Usually of sudden advent. 
Chill — rare. 
Fever. 

Pain — in one or more of the joints, which usually increases, and 
is worse on motion. 

Swollen and tender joints — the large joints are principally af- 
fected. 

Skin over the joint — may be normal, of a light or dark-red color. 
Temperature— usually 100°-10r; may rise to 104°-105°. 
Pulse— full and soft, 90-100; may rise to 130. 
Perspiration — peculiar acid. 
Great thirst. 

Urine — scanty, high sp. gr. ; urea increased. 

COMPLICATIONS. 

Peri-carditis ; endocarditis; myo-carditis; pleurisy; pneumonia; 
cerebral and spinal meningitis ; and pyaemia, from suppuration. 

CAUSES OF DEATH. 
Death may occur from complications, or sudden collapse from 
an effect upon the nervous system. 

DIFFERENTIAL DIAGNOSIS. 
From synovitis; arthritis; and gout. 

PROGNOSIS. 

It usually terminates in complete recovery, provided there be 
no complications. Young subjects are very liable to have cardiac 
complications from endo-carditis and endarteritis. 



384 



DISEASES OF THE BLOOD. 



TREATMENT. 

The patient should live in a country where the atmosphere is 
dry, and with a temperature ranging about 70°; his body should 
be covered with flannel. The affected joints should be packed in 
a poultice made of bicarb, sodii, bound round with cotton wool, 
and covered with oil-silk. All animal food should be withheld, 
and the diet consist of milk with an alkali. Lime juice may be 
drank, or lemons eaten, with advantage, as in the body this acid 
is changed into an alkali. In some cases a hot pack may be found 
to greatly relieve the sufferings of the patient. Should there be 
great pain, opium may be given, and in the event of swelling, the 
parts may be painted with iodine. If meningeal troubles occur, 
leeches and cold compresses should be applied to the head. In a 
few cases, salicylate of soda will sometimes stop the disease. 
JPulv. sodii bicarb, and pulv. acidi tartar, may be given as an 
effervescing drink. The Germans advise giving salicylate of soda 
(gr. x.-xv.) every four hours, or capsules of scdicylic acid, gr. x., 
every two hours, and crowding them continuously. 



CHRONIC ARTICULAR RHEUMATISM. 
MORBID ANATOMY. 
The sjmovial capsule and ligaments of the joints will be found 
to be thickened; hypertrophy or degsneration of the membranes 
may exist; the cartilages are often relaxed and shaggy; and the 
synovial fluid cloudy. It may attack only one joint at a time, 
sometimes inducing comparatively little anatomical change. It 
may lead to suppuration of the joint, and caries of the end of the 
bone. 

ETIOLOGY. 

It may occur from congenital predisposition; from previous 
attacks; from catching cold; or remaining in cold, damp, windy 
places. 

SYMPTOMS. 

Pain — constant and increased, especially at night, on pressure or 



CHRONIC ARTICULAR RHEUMATISM. 



335 



active motion; or it may only occur at every change of the 
weather. 

Crackhng sensation or crepitation felt if the hand be placed on 
the joint when motion is made. 

Swelling — (fr ^m increase of synovia, and thickening of the cap- 
sule and ligaments). 

Prominence of the joint — which may be swollen and painful. 

Fever — may occur, with frequent pulse, and profuse perspiration. 

Urine — thick and sedimentary. 

Emaciation. 

It may be complicated with neuralgia and paralysis. 

DIFFERENTIAL DIAGNOSIS. 
From chronic gout. 

PROGNOSIS. 
This disease often ends in a permanent deformity. 

TREATMENT. 

Flannel should always be worn next to the body. Iodide of 
potassium, guaiacum, oil of turpentine, and cod-liver oil axelargely 
used in this affection, but local treatment is found to give more 
relief. The inflamed part may be painted with the tincture of 
iodine or a lotion composed of tr. iodine, 3ss.; pot. iodide, 3 ss. ; 
aquae, § iij. may be applied; or a liniment containing oil of tur- 
pentine, oil of sassafras, ammonia, and laudanum diluted with 
soap liniment; or when the pain is excessive, chloroform or aconite 
liniment may be used. Blistering may even be resorted to in bad 
cases. Where there is rigidity of the joints, and even pain in 
them, or, in the muscles, hot ivater may be constantly poured 
over the parts. Some prefer the hot water or vapor bath and 
others the hot dry air bath at a temperature of about 130° to 200°, 
as a means of affording great relief. In order to aid in the 
Testoration of the stiffened parts, eiectriciiy should be resorted to. 



336 



DISEASES OF THE BLOOD. 



MUSCULAR RHEUMATISM. 
ETIOLOGY. 

It is a rheumatism of the muscles, fascia, periosteum, and other 
fibrous tissues; the changes consisting chiefly of hypersemia and 
scanty exudations. It is diffcult to say whether the sensory 
nerves traversing the muscles are morbidly excited by changes 
in the muscles and sarcolemma, or whether simultaneous changes 
occur in the neurolemma. 

SYMPTOMS. 

Pain— designated as stretching or tearing; it is increased by mo- 
tion and cold applications; diminished by pressure and warm 
applications, and may be wandering or fixed. 

Neck— may be stiffened (as its muscles are most often affected). 

TREATMENT. 

The parts should be painted with iodine, or a blister in some 
form. One of the most effective rubefacients is the appUcation of 
the induced current by means of the electric brush. Vapor baths 
may prove of great relief to the patient. Should there be great 
pain, the hypodermic use of morphia can be resorted to. 

DIABETES. 
VARIETIES. 
Mellitus " and " Insipidus." 

DIABETES MELLITUS. 

SYNONYMS. 
' ' Glycosuria; " ' ' milleturia. " 

DEFINITION. 
Is characterized by excessive and saccharine urine. 



DIABETES MELLITCrS. 



33? 



MORBID ANATOMY. 
Is obscure. Physiologists claim, from experiments, the probable 
seat of the disorder is in the liver (due to its glycogenic function). 
It is also claimed that, by irritating the fourth ventricle of the 
brain, sugar can be produced in the urine. It is also regarded as 
a nervous disease, through the pneumo-gastric nerve; for if you 
cut the pneumo-gastric, no sugar will be found in the liver after 
death. 

ETIOLOGY. 

Predisposing causes. — It occurs more frequently in men than in 
vromen, especially the young and middle-aged adults. It may be 
hereditary, or occur from nervous shocks. 

Exciting causes. — Exposure to wet or cold; drinking cold water 
in large quantities when the patient is heated; intemperance; 
fevers; injuries to the brain and spinal cord (through the pneumo- 
gastric). 

SYMPTOMS. 

Come on slowly with malaise. 

Thirst -incessant (a prominent symptom). 

Emaciation. 

Insatiable hunger. 

Excessive micturition. 

Urine— pale straw color, sp. gr. 1030 to 1050. Patients have 
been known to pass seventy to eighty pints in twenty-four 
hours. 

Anaemia. 

Dyspeptic symptoms — due to faulty secretion of the gastric juice. 

Palpitation of the heart. 

Vertigo. 

Tongue— is glazed and furrowed. 
Mouth — clammy . 

Failure of mental and sexual powers (the latter may be sometimes 
increased). 

COMPLICATIONS. 
Tubercular phthisis; furuncles and anthrax; gangrene of the 
lower extremities; defective vision; cataract; pruritus vulvae; 
erysipelas, etc. 



338 



DISEASES OF THE BLOOD. 



CAUSES OF DEATH. 
Fever; oedema; diarrhoea; and probably oedema of the lungs, or 
over-working of the kidneys or some other organ may produce 
death. 

PROGNOSIS. 

Is unfavorable, although recovery is not impossible, usually lasts 
from one to three years. 

TREATMENT. 

The tests applied for sugar in the urine are principally Moore^s 
Tromer's, and Fehling's. It is the weight of the patient that 
denotes improvement in the disease and not in the amount of 
sugar passed . Prohibit the use of sugar or starchy food, as bread 
(except bran bread), potatoes, cabbage, broccoli, celery, lettuce, 
spinach, and onions. Milk aijd liver should also be amongst the 
number. The patient should be fed on meat, eggs, butter, jellies, 
aerated bread, tea and coffee not sweetened. Stimulants must be 
avoided, but water may be used ad libitum. 

Medicinal agents are of no use, excepting opium. Codeia espe- 
cially. Oleum morrhuce may be given to keep up the strength of 
the patient, or rub the surface of the body with oil. The radical 
cure for this disease has not yet been discovered 

DIABETES INSIPIDUS.' 
SYNONYM. 

''Polyuria." 

DEFINITION. 

There is an excessive amount of urine passed, which is of a 
light color, light in weight, and contains neither sugar nor albu- 
men, but is accompanied by excessive thirst (polydipsia). 

MORBID ANATOMY. 
Is obscure. There is generally atrophy of the kidney or renal ' 
congestion associated with this variety of diabetes. It is stated 
that the immediate cause of this disease is dilatation of the capil- 
lary vessels of the kidneys, due to disturbance of the ganglio- 



SCURVY. 



339 



nervous system which controls the circulation of that organ. 
The disease may last from a few weeks to many years, and may 
be congenital. 

ETIOLOGY. 

From blows on the head; exposure to cold; drinking cold fluids 
when the patient is heated; cerebral disease; intemperance. 

SYMPTOMS. 

Usually sudden. 

Intense thirst. 

Skin — dry and harsh. 

G-reat emaciation and debility. 

Excessive urination — about fifty to seventy pints (passed in a day), 
TREATMENT. 

No specific cure has yet been discovered. The only treatment 
is to hold the disease as much in check as possible. The follow- 
ing drugs have been suggested: nitrate of potassium, valerian, 
ergot, iron, alum, lime-water, tannic and gallic acid, bromide of 
potassium, etc. Also blistering the nape of the neck. 

SCUEVY. 
SYNONYM. 

''Scorbutus." 

DEFINITION. 

Is a peculiar form of anaemia, arising from deficiency of veget- 
able diet, attended with a tendency to the occurrence of hemor- 
rhages, impairment of nutrition, and great mental and bodily 
prostration, 

MORBID ANATOMY. 

The body will be found to be greatly emaciated. Slight oedema 
will exist, especially of the lower extremities. Extravasations of 
blood may be found not only in the superficial regions of the body, 
but in the substance of the lungs, beneath the pleura, in the walls 



340 



DISEASES OF THE BLOOD. 



of the heart, in the intestinal parietes, and beneath the perito- 
neum. There may be ecchymosis between the serous and muscu- 
lar coats of the intestines. The mucous membrane of the intes- 
tines is reddened, swollen, and relaxed. Bloody serum may form 
in the serous cavities. The blood is of low specific gravity; there 
is a diminution in the red blood-corpuscles and an excess of fibrin. 
The joints are greatly enlarged. The gums will exhibit typical 
changes. 

ETIOLOGY. 

From insufficiency of or a total absence of fresh vegetables; 
from a decrease in the alkaline salts of the blood (salts of potash); 
from the constant use of salt meat, and long-continued exposure 
to privation, fatigue, and mental anxiety. 

SYMPTOMS. 
Anaemia — rapid and progressive. 
Skin — has a dirty-looking, pallid, or eaithy aspect. 
General debility and cachexia. 
Pains in the back and limbs. 
Mental apathy and depression. 
Tongue — large, flabby, and indented. 
Constipation. 

Spots— (petechial) first on the legs, and then extending over the 
surface. 

Puffy swellings — in different parts of the body, due to deep-seated 

hemorrhages, especially in the popliteal space and elbows. 
Bleeding and swelling of the gums, also ulceration or sloughing. 
Loosening and dropping out of the teeth. 
Foetid odor of the breath. 

Later on. > 
Puffiness of the face. 
Anasarca of the extremities. 
Dyspnoea. 

Palpitation of the heart 
Sudden syncope. 
Offensive diarrhoea. 
Disturbed vision. 



PURPURA. 



341 



Tinnitus aurium. 
Vertigo. 
Want of sleep. 
Delirium. 

CAUSES OF DEATH. 
Death may occur from exhaustion or sudden syncope. 

DIFFERENTIAL DIAGNOSIS. 
From purpura. 

PROGNOSIS. 

Is good. These patients usually recover rapidly when fed on 
lemon- juice, fruits, and vegetable food. 

TREATMENT. 

Patient should have plenty of vegetables, lime-juice, and wine. 
Administer tinct. ferri chlor. in moderate doses. For the gums, 
a wash of tannic acid or tincture of myrrh in dilute glycerin ; or 
alum, brandy, and water. Rub the body, or parts where the 
eruption is, with salt and whiskey. 

' PURPURA. 
SYNONYMS. 

Purpura haemorrhagica; morbus maculosus Werlhofii. 
DEFINITION. 

Is an affection characterized by the extravasation of blood in 
the form of spots beneath the surface of the skin. These are 
unaffected by pressure. When they are small and round in shape 
' they are termed "petechia;" when elongated in strips (like a 
whip), " vibices;" when diffused or irregular (like a bruise), " ec- 
chymomata." 

MORBID ANATOMY. 
Is obscure. Hemorrhages, like those of the skin, are sometimes 
discovered in the sub-serous and sub-mucous tissues, and less so 
in the various organs. The primary morbid condition is probably 
in the capillary and other small vessels, rather than in the blood, 



342 



DISEASES OF THE BLOOD. 



and the blood escapes into the tissues in consequence of capillary 
rupture. 

ETIOLOGY. 

It occurs at all ages, but chiefly in young children, who have 
delicate skins. It is thought by some to arise from bad hygienic 
surroundings, and in those who are under-fed, and sickly, and 
yet is observed among those who live with every comfort and 
good hygenic surroundings. One feature in this disease is that it 
is very apt to recur. 

SYMPTOMS. 
Usually ushered in with general malaise and fever. 
Pain — in the lower extremities (especially in the legs). 
Swelling of the affected limbs. 

Skin— studded with red spots, usually about the size of a millet 

seed, which do not fade on pressure, but generally disappear 

in a few days. 
Epistaxis— may occur. 
Bleeding of the gums. 
Loss of muscular strength. 
Mental dejection, 
in a severe case. 

Bleeding from various organs. 

Countenance — pallid. 

Pulse — increased and jerking. 

Tinnitus aurium. 

Pupils — dilated. 

Headache. 

Muscae volitantes. 

Delirium. 

Mania. 

Convulsions or death. 

CAUSES OF DEATH 
Death may occur from asthenia or syncope. 

TREATMENT. 

In mild cases the patient usually gets well without any treat' 



GOUT. 



345 



/nent. Among the remedies which have been extensively used as 
styptics are perchloride of iron, acetate of lead, arsenic, digitalis, 
turpentine, and gallic and sidphuric acids. The body should be 
sponged with alum and brandy, or whiskey and water, at a tem- 
perature that is not chilling, and yet is sedative to the circulation. 

GOUT. 
SYNONYMS. 
' ' Podagra ;" and * ' arthritis. ' ' 

MORBID ANATOMY. 
There is an inflammation of the joints with deformity, and in- 
crustation of the serous sacs of tho joints, with a chalky material 
(urates of soda). It usually commences first in the joint of the 
great toe, although any joint may be affected. Fibroid degenera- 
tion of the blood-vessels may also ensue. The left ventricle of 
the heart may become hypertrophied. 

ETIOLOGY. 

It is said to be caused by an excess of uric acid in the system. 
It seems to arise from an hereditary tendency; from too high living; 
from the consumption of too much nitrogenized food and an in- 
sufficiency of oxygen introduced into the system; from plugging 
of the uriniferous tubules, producing subsequent atrophy of the 
kidneys. It usually occurs in men, after thirty years of age, who 
have led a luxurious and idle life. 

SYMPTOMS. 

Malaise. 

Pain — severe, piercing, burning most often in the great toe. The 

attacks usually begin about midnight. 
Joint — swollen and red. 
Fever. 

Pulse — full and bounding. 
Skin— dry. 



344 DISEASES OF THE BLOOD. 

Thirst — intense. 

Mental excitement. 

Leg — swollen (by oedema). 

Chalky deposits about the joints (occur late). 

Hands and arms — become involved (later on). 

Cachectic look. 

If in the stomach. 

Cardialgia. 

Vomiting. 

Haematemesis. 
If in the brain. 

Apoplexy, or circumscribed headache. 

Dizziness. , 
If in the heart. 

Irregular and feeble action. 
Disturbed circulation. 
Dyspnoea. 
Fainting. 

The bladder and kidney may be affected by the gouty diathesis. 

CAUSES OF DEATH. 
Death usually results from complications or internal gout 

PROGNOSIS. 

Is unfavorable as to a permanent cure. Patients are apt to die 
between the ages of forty-five and sixty years. 

TREATMENT. 

The patient should be placed under a certain regime. The fol- 
lowing system will greatly aid in relieving the sufferer : 

(1) The diet should consist principally of vegetables, soups, 
cream, and milk; meat may be taken sparingly once a day. 

(2) Wines, spirits, and fermented liquors should be forbidden, 
and even tea and coffee. 

(3) The patient should drink water freely (as it irrigates the 
kidneys), also Vichy, or any mineral water, and should eat lemons 
or take iced acid drinks. 

Tincture of colchicum, gtt. xx.-xxx,, may be given three times 



DIPHTHERIA. 



345 



a day or colchicum and iodide of potassium in combination ; or 
Reynold's or Seville's specific or Lee's lithontriptic pills; these 
latter have proved to be a great source of comfort to the patient ; 
or ipecac, hydrarg. chlor. mite, aa gr. i. ; aloes, extractum colch. 
acet. ext. nucis vom., aa gr.3^. Fiat pil. Sig. Give one eveiy 
four hours till purged. 

To relieve the pain, opii gr. j. or morph. sulph. gr. }^ may be 
given. 

DIPHTHEEIA. 
SYNONYMS. 

"Pseudo-membranous angina;" "putrid sore throat;" "diph- 
theritis." 

DEFINITION. 

Is a disease characterized by a membranous exudation, which 
usually appears first on the tonsils. It may extend backward and 
upward, involving the i^osterior nares; or downward, involving 
the oesophagus and stomach, or respiratory tract. It may occur 
wherever mucous membranes exist, or even on a blistered surface, 

MORBID ANATOMY. 

On examination, the first thing that will be noticed is a redden- 
ing of the mucous membrane, which soon becomes purple in 
color (from passive congestion), and a slight infiltration of serum 
into the tissues (oedema) simultaneously appears. The epithelium 
covering the mucous membrane soon becomes cloudy and gran- 
ular (resembling in appearance a light gauze which has been 
thrown over the mucous membrane). In the mildest cases the 
disease may stop at this stage, because this granular surface is of 
a low vital power, and cannot, therefore, organize. 

In the next stage, the sub-epithelial layer becomes infiltrated 
with the same granular substance, which continues to progress 
until the whole of the mucous and sub-mucous tissues are in- 
volved. 

The exudation varies in color and extent; it may, in one case, 
be pearly white, and cover over the surface; in another, it may 



346 



DISE..SES OF THE BLOOD. 



assume the buckskin appearance, covering the pharynx or tonsils; 
while in another it may be dark-gray in color, resembling gan- 
grene, indicating extensive blood changes (the amount of exuda- 
tion foretelling the severity of the disease). When the exudation 
is granular in character, the cells are changed tissue-cells, giving 
it the appearance of a mixed exudation. This is the lowest grade 
of inflammation, from which recovery is hardly possible; it re- 
sembles a caseous material, which cannot be re-absorbed, and is 
only removed by the removal of the epithelial covering. Should 
the exudation occur in the mucous and sub-epithelial tissues, and 
not be very abundant, it may be arrested by overcoming the 
poison. When this has been accomplished, simple epithehal and 
sub-epithelial cell development occurs, with a rapid suppurative 
process, terminating in a suppurative infiltration. 

In addition to these local changes, on post-mortem examination, 
the blood will be observed to be much darker than normal. It 
undergoes rapid ammoniacal changes, and does not coagulate. 

The heart will be found to be soft, and a granular degeneration 
of its muscular fibres will usually exist. 

In the stomach, the mucous membrane will be found soft and 
oedematous. 

In the intestines, the glands and Peyer's patches will be soft and 
enlarged. 

TJte lungs will be congested (splenization), and the bronchi may 
contain the exudation. 

The liver will also be congested, and the spleen enlarged and 
softened. 

In addition to the foregoing changes in the blood and organs, 
there may also be those which resemble typhoid fever so closely 
that it will be almost impossible to distinguish the two diseases. 
Under these circumstances, the exudation must be present to 
decide it. 

The first action of this disease is to destroy life, which it does 
by attacking the epithelial, sub-epithelial, and mucous tissues. 

ETIOLOGY. 
The questions which naturally arise are: 



DIPHTHERIA. 



347 



First. — Is diphtheria a contagious disease? There is no doubt 
that it is a contagious disease, and can be developed by inocula- 
tion in the same manner as small-pox. 

Second.— Is, it a constitutional disease primarily, and local 
secondarily, or vice versa ? It cannot be well denied that it is first 
a constitutional, and, secondly, a local disease; for it seems proven 
there is a local manifestation of a constitutional development by 
the fact, that the disease cannot be destroyed by taking off the 
various layers of the mucous membrane. It is unquestionably a 
constitutional disease, and the local changes depend entirely upon 
the amount of infection. 

Third. — Is it of spontaneous origin ? It is like typhus and ty- 
phoid fevers, requiring a poison through decomposing animal 
matter, which fills the air. That it also occurs in connection with 
sewer poisoning there is no doubt, still the profession is very un- 
decided on this point. It is a contagious disease, and has no ap- 
parent governing law. It may be communicated and produced, 
or transmitted, by the exhalations. It is claimed by some that 
this disease is due to some special germ. (This is not yet proven. ) 
SYMPTOMS. 

Local. 

Chills, fever, and active symptoms, with rapid pulse, in some 
cases precede the disease; while in other cases it comes on 
insidiously, and, only for the exudation, it might escape 
observation. 

Exudation {is characteristic)— xjiS\X3i\\j commences on the ton- 
sils. It may extend backward and upward, or to the soft 
palate and pharynx, and into the posterior nares. or 
downward into the oesophagus and stomach, or into the 
larynx, and even to the lungs. 

Pricking sensation in the tonsils, often extending down the 
throat. 

Pain — in the throat and pricking sensation in the larynx. 

DifiS-Culty of deglutition — (from extension of the exudation 
into the oesophagus). 

Voice — becomes changed, husky, and, finally, lost (from ex- 
tension of exudation into the larynx). 



348 



DISEASES OF THE BLOOD. 



Respiration — difficult both on inspiration and expiration, and 
wheezing in character (from extension of the exuda- 
tion into the larynx). 

Cough — abortive and stridulous (from extension of the ex- 
udation into the larynx). 

Restlessness and jactitations — (indicating changes in the oxy- 
genation in the blood). 

Cyanosis. 

Stupor and coma— (from excess of carbonic acid in the lungs). 

Glands of the neck — enlarged (sub-maxillary gland is involved 
only when the exudation is on the tonsils, pharynx, and 
posterior nares, from extension of the poison through the 
lymphatic channels). 

Puffing of the face may occur. 

Death — may result from croupous laryngitis. 
Constitutional — vary with the amount of poison in the system. 

Pain in the bones. 

Chilliness or violent chills. 

Temperature — may rise to 105°-106°, or may not rise over 
102°-103°. 

Pulse— accelerated from 100 to 150. In some cases becomes 

irregular and intermittent. 
Countenance —has a lethargic expression (in some cases). 
Special symptoms— indicatiYe of danger to the patient. 

1. Extension of the exudation into the larynx — (from which 

few ever recover), producing change in the voice and a 
stridulous cough, which tells of danger and almost cer- 
tain death. 

2. Appearance of the exudation — which may be dark-gray, 

greenish, or black, involving the whole of the posterior 
walls of the pharynx and nares. It often emits an odor, 
resembling gangrene when the danger is great. Septic 
symptoms then develop, with fever and a high range of 
temperature, etc. Septicaemia may be ushered in by a 
chill, and followed by lethargy, stupor, peculiar offensive 
odor, disposition to a typhoid condition, and delirium 



DIPHTHERIA. 



349 



terminating in death (which is due to long-continued 
blood-poisoning). 

3. Vomiting. — If it occur early, is not of very great import- 

ance; but, if late, then it is a grave symptom, indicating 
danger. It is not due to the shock of the poison, but to 
a secondary poison, and the patient often passes rapidly 
into collapse. 

4. Nausea and diarrhoea — occurring late in the disease, are 

grave symptoms. 

5. Pulse. — This is of three varieties: 

1st. — It may be rapid from the beginning and continue 
throughout at 140 to 180. This is due to the action of the 
poison on the pneumogastric nerve. 

2d. — It may be rapid from the beginning and suddenly go 
down to 60 or 80, and afterward become intermittent. 
This is due to the action of the poison on the sympathetic 
system. 

3d. — There may be marked irregularity from the onset. It 
may be intermittent and rapid at first, then becoming 
slow, or vice versa. This is due to the action of the 
poison on the cerebro-spinal system. 

6. Paralysis of the muscles of the larynx, neck, arm, etc. 

7. Low temperature and cold surface, accompanied by a 

cyanotic condition. Even if the pulse be rapid and not 
intermittent and irregular, this is unfavorable. It de- 
notes action of the poison on the nerve-centres. 

SEQUELS. 

The most frequent is that of paralysis of the pharynx, larynx, 
arms, lower extremities, bladder, penis, etc. There are no medi- 
cal means which can restore the normal power, the action of the 
muscles seems to be lost for a certain time, and then to return 
to their normal condition; thus clearly proving that there is no 
great structural lesion in the nerve-centres. 

Another sequela is parenchymatous nephritis, which com- 
mences in the uriniferous tubules. These are filled with an ex- 
udation the same as in other infectious diseases. There may be 



350 



DISEASES OF THE BLOOD. 



a granular exudation of the uriniferous tubules, going on from 
one step to another until it produces total destruction and intense 
engorgement of the kidneys, resulting in blood in the urine, etc. 
Ursemic symptoms will then be developed, and the patient may 
die in convulsions from ursemic poisoning. The diphtheritic 
renal changes are sometimes the cause of chronic Bright's, 
having its origin in a parenchymatous inflammation from the 
result of diphtheritic inflammatory changes. 

COMPLICATIONS. 

Endocarditis. — This is usually of an ulcerative type, and occurs 
after the exudation has disappeared. It requires more than a 
simple irritation of the blood passing over the endo-cardial surface 
to produce it, and denotes very extensive constitutional poisoning. 

Meningitis. — If it occur at all, appears early in the disease. 

Hemorrhage of the bowels. 

Jaundice. — (From extension of the exudation along the line of 
the hepatic duct). The inflammation occurs in the smallest tubules 
of the liver. 

The inflammatory process may occur in the smallest bronchi in . 
the lungs, extending downward from the larynx, or it may com- 
mence in the bronchi and extend upward. There is no mucous 
membrane in the body that may not become involved. 

DIFFERENTIAL DIAGNOSIS. 

Bests entirely upon the presence of an exudation, which usually 
shows itself first on the pharynx. Unless the exudation be per- 
ceived on some mucous surface, and there be marked constitu- 
tional disturbances, the diagnosis of diphtheria cannot be made. 
It may be diagnosed from catarrhal pharyngitis, membranous 
croup, typhus or typhoid fevers, and ulcerative endo-carditis. 

In catarrhal pharyngitis — you have no gray exudation, and the 
patient gets well in from four to five days. 

In membranous croup — the membranes are superficial, and 
there are no constitutional disturbances. They are simply local. 

In typhus and typhoid fevers. — It is very difficult to decide 
^ such cases as these, for, whenever the exudations occur, it will 
always be along the intestinal tract, and rJl that can be done, 



DIPHTHERIA. 



TAnder these circumstances, is to watch the discharges for two or 
three days, and also the matter that may t e vomited, when the 
exudations may be perceived. 

In ulcerative endocarditis. — The patient first complains of sore- 
throat; he is seized with pains in the back, perhaps hemiplegia, 
and suddenly becomes unconscious; the pulse will be irregular, 
a mumbling delirium may be present. On examining the heart 
it will be found to have a tumbling motion and extensive valvular 
lesion; under these circumstances examine the posterior nares, 
when you will be certain to find a small mucous patch of exuda- 
tion, which will confirm your diagnosis. 

PROGNOSIS. 

Depends upon whether there is an epidemic raging, and also 
upon the stage of the epidemic; the fatahty being worse in the 
early stage. It is apt to demolish a whole township of children. 
Age is an important element of prognosis; for, the younger the 
the child, the worse the prognosis, as death seems to result from 
obstruction in the pharynx (and consequently from an inability 
to feed the child), and further, from the excess of poison in the 
constitution. When it attacks the adult, the prognosis is more 
favorable. The character of the exudation is an aid in the prog- 
nosis; for, the darker, and thicker, and more extensive the 
exudation, the worse the prognosis. If it attack the posterior 
nares, and extend upward, if the glands become enlarged, and the 
constitutional symptoms are severe, the prognosis is grave; but, 
so long as the exudation confines itself to the fauces and anterior 
pillars of the pharynx, and spreads, hut is not thick, even though 
other symptoms be severe, the prognosis is favorable. Should the 
exudation extend downward into the larynx and respiratory 
tract; or into the oesophagus, it will then be unfavorable. 

If the exhalations from the throat be offensive, and, following 
the shock, there be evidences of septic poisoning, the prognosis is 
bad. Should pharyngeal paralysis occur before the exudation 
has disappeared, recovery is hardly possible, as deglutition be- 
comes involved, and death resulting from inanition. The paraly- 
sis which comes on after the disappearance of the exudation is 



352 



DISEASES OF THE BLOOD. 



usually recovered from, yet there is one form of paralysis which 
destroys life, and that is when the intercostal muscles are para- 
lyzed, accompanying paralysis of the diaphragm (since the patient 
then dies from inability to respire). 

Should the slow pulse come on after a fast pulse, it may be re- 
covered from ; but, if in addition to the slow pulse it becomes in- 
termittent, the prognosis is bad. 

TREATMENT. 
May be divided under four headings: 

1. Hygienic. 

2. External local. 

3. Internal local. 

4. Constitutional. 

Hygienic. — The patient should be placed in a large, well- venti- 
lated room, the temperature of which should range from 68^ to 
72°. Great care should be exercised in regard to cleanliness, for 
there is no disease in which cleanliness is so important. The bed 
and body-linen should be carefully cleansed; the patient should 
be quarantined, and all other children removed from the house, 
or kept away from the apartment. It is best to place the patient 
in an upper sunny room, provided, if possible, with an open fire- 
place; everything which can be dispensed with, such as books, 
clothing, carpets, window curtains, etc., should be removed, be- 
cause when once the patieiit has entered the room, nothing can 
with safety be removed until disinfected or fumigated. One or two 
adults should take the entire charge of the patient, under no cir- 
cumstances coming in contact with other persons, especially chil- 
dren. Great care should be observed not to inhale the breath of 
the patient, and parents should be prevented from kissing the 
child. All soiled linen, and also every article used in the room, 
should be thoroughly disinfected before it leaves: this can be 
easily accomplished by obtaining one pound of sidplmte of zijic: 
place eight tablespoonfuls of this, with four of common salt, in 
an ordinary water pail, and, to them add one gallon of boiling 
water. This disinfectant solution must be kept in the sick-room, 
and into it should be placed, and kept for one hour, every article 



DIPHTHERIA. 



353 



of soiled clothing, bedding, etc.; when they are removed from 
this they mnst be put into boiling water before being washed. 
The dishes and spoons used by the patient should be put into 
boiling water before they are permitted to leave the room. It 
must be borne in mind that every article which is in the room can 
convey the disease, and that nothing should go from it until the 
poison, which they might carry, has been destroyed. 

Be very careful when making an examination that the breath is 
not inhaled, nor the sputa gain entrance into your mouth. Avoid, 
as much as possible, manipulation and inspection of the throat, 
as it produces irritation, and will necessarily increase the exuda- 
tion ; examination should always be made with the utmost care, 
and not too frequently. One of the principal features in the treat- 
ment of this disease is absolute rest in the recumbent position, and 
the patient should not be allowed to move about or walk. The 
diet should consist simply of milk, and given in small quantities. 
The body should be carefully sponged, and the nasal passages 
syringed out once a day, with a half per cent solution of carbolic 
acid, but care should be taken not to exhaust the patient. The 
windows of the sleeping-room should be opened, as long as pos- 
sible, every day, as fresh air is about the best disinfectant; but 
draughts and chilling the patient should be carefully avoided, 
and see that a fire is kept burning in the room, day and night, 
during cold weather. 

External local. — This consists of 

(1) Blood-letting — by the application of leeches to the angle of 

the jaw. 

(2) Cold — by means of the ice-bag. 

(3) Counter irritation — in the form of blisters, etc. 

(4) Hot applications and hot poultices. 

Of these, the preference must be given to the hot application 
(which should be covered over with oiled-silk when applied) and 
hot poultices, because, so long as there is a granular exudation 
into the membranes, and it can be converted into a serous, the 
sooner it will cease. These hasten suppuration, and should, there- 
fore, be applied regularly and carefully at the seat of exudation. 



354 



DISEASES OF THE BLOOD. 



Internal local, 

1. Mechanical. 

2. Escharotics. 

3. Astringent. 

4. Antiseptic. 

With regard to the fii-st three methods, it is hardly necessary to 
assert that they are only detrimental, as they tend to aggravate 
the part and cause the exudation to infiltrate the deeper tissues, 
and produce gangrene and sloughing. The exudation should 
never be removed, unless you find a part that has sloughed and is 
pendant; it should then be drawn forward and cut off. The 
question naturally arises; you require to start a suppurative pro- 
cess under the exudation. What is to be done ? What shall be 
used ? Steam should be used, as it is the most grateful course 
that can be pursued for the patient, because it tends to produce 
suppuration; therefore, apply hot poultices externally, and cause 
steam to he inhaled; and, so soon as the removal of the exudation 
is observed, you know your patient has had a local affection; 

What is to be done with the septic poison ? Use antiseptics by 
means of the spray, with a weak solution of carbolic acid or 
chlorine water, and a very weak solution of the muriate tincture 
of iron; or give the patient muriate tincture of iron, gtt. v. , with 
glycerin; or chlorate of potash, gr. v., with glycerin, and let him 
swallow it, as it acts in the same way as the spray when that plan 
cannot be resorted to. 

Constitutional. — From the onset there are evidences of failure 
of vital power and loss of all symptoms of vitality, the patient 
dying, as they do in all infectious diseases, from the direct effect of 
the over-charging of the poison. The disease must, therefore, be 
treated in all ways, as the other infectious diseases. Muriate tinc- 
ture of iron should be given from the commencement. As stimu- 
lants, alcohol or brandy stand first, but should not be used unless 
the system is very much disturbed constitutionally, as they are not 
required; but, so soon as you find the patient becoming apathetic^ 
the pulse feeble, and more frequent, and perhaps becoming irreg- 
ular, the tongue dry, and the exudation dark and offensive, then 
crowd your stimulants, the first few doses of which should be 



RELAPSING FEVER. 



355 



carefully watched, and it may even be necessary to give as much 
as a tablespoonful every hour to a young child. Milk should be 
the diet^upon which the patient should be fed ; if it cannot be 
swallowed, it must be given by the rectum. Should there be 
restlessness and jactitations, opium may be given in moderate 
doses, but not sufficient to produce narcotism. 

In the laryngeal or pharyngeal complications malt liquors should 
be given and as much as the patient will take, all other methods of 
treatment being of no avail. 

In cardiac diseases opium judiciously administered will have a 
beneficial effect, but in children the only preparations which should 
be given are Pulv. Doveri. and tinet. opii camph. 

When kidney complications occur they must be treated in the 
same manner as acute parenchymatous nephritis. 

RELAPSING FEVER. 
SYNONYM. 

Famine fever. 

DEFINITION. 

Is ah epidemic fever, characterised by a sudden invasion and 
persistent high febrile symptoms without remisssion ; temperature 
rising to 107°-108°. There is a rapid subsidence within a week and 
then a relapse, usually, within seven days after the first attack. 
The temperature in this fever rises higher than in typhoid. It is 
claimed that the disease is due to spirilloe within the blood. 

MORBID ANATOMY. 

The lesions occurring in this disease will be found in the spleen, 
liver, kidneys, intestines, mucous membranes and the blood. 

Spleen — may be increased in size ; its capsule thickened, smooth 
tense and slightly cloudy ; its trabeculoe increased in size ; and 
the Malpighian tufts more prominent than normal, or it may be 
enlarged, soft and flabby. 

Liver — may be enlarged ; the structural changes will be the 
same as those in the spleen. The gall-bladder may be distended 
with bile of a dark yellow color. 



356 



DISEASES OF THE BLOOD. 



Kidneys — increased in size which is due to congestion of the 
cortical substance and a granular infiltration of the epithehum of 
the uriniferous tubules. 

Intestines — glandular follicles will be enlarged. The solitary 
glands are principally affected and Peyer's patches may have the 
shaven-beard appearance. The mesenteric glands may resemble 
those of typhus or typhoid fever. 

Mucous membranes. — Those of the stomach and intestines are 
principally affected having small spots of blood-extravasation up- 
on their surfaces, but these extravasations may also occur on the 
mucous membranes of the bronchial tubes. 

Blood — coagulates imperfectly. Some authorities claim that 
spirillse are always present in the blood of patients afllicted 
with this fever. 

ETIOLOGY. 

It is said to oe due to spirillse in the blood having the power of 
de\^eloping the fever. It seems to be developed by squalor, poor 
quality of food, and bad hygienic surroundings. It may be traced 
to direct contagion. 

SYMPTOMS. 

Advent is sudden. 
Chill — distinct. 

Frontal headache (which increases with the fever). 

Pam in the muscles and joints — (which increases with the. fever). 

Nausea. 

Vomiting — at first, contents of the stomach, then a yellowish 

material, and subsequently of a dark color resembling the 

black vomit of yellow fever. 
Temperature — rises rapidly especially during the first twenty-four 

hours ; may reach 104° or even 109° and may last for two or 

three days. 

Pulse — may reach 140 to 160 during the first twenty-four hours 

and is small and compressible. 
Respiration — hurried and irregular. 

Great prostration and emaciation. 

Weight and uneasiness in the abdomen, especially in the right 
hypochondrium. 



RELAPSING FEVER. 



357 



Liver — enlarged and tender. 
Spleen — enlarged and tender. 

Muscular pains — Severe and increased by motion and pressure 
and is of a piercing and lancinating character, and patient lies 
perfectly quiet and sleepless in consequence. 

Delirium — may occur and be active in form. 

Pupils — may be irregular. 

Photophobia — may occur. 

Jaundice — may occur with vomiting and diarrhoea. 
Eruption — may occur, resembling roseola. 

Perspiration — profuse about the seventh or eighth day of the fever 
when the temperature falls and the symptoms abate. 

Hemorrhage — from the nose, bowels, or intestines may occur. 

Relapse — may occur from the third to the seventh day after the 
symptoms abate which last about four days. 

CEdema of the feet — may occur during convalescence, due to great 
ansemia. 

CAUSES OF DEATH. 

Deaths usually occur from complications and not from the dis- 
ease as from diarrhoea and dysentery during convalescence ; from 
pachymeningitis ; from hemorrhage from some of the mucous sur- 
faces ; from syncope during relapse ; from bronchitis, pneumonia 
or pulmonary complication; from suppression of urine producing 
uraemia. 

COMPLICATIONS. 
Pneumonia which is often double ; sudden collapse ; post feb- 
rile ophthalmia attacking most frequently the right eye ; diarrhoea 
and dysentery. 

DIFFERENTIAL DIAGNOSIS. 

Is not difficult. It may be confounded with typhus fever ; ty- 
phoid fever ; remittent fever ; yellow fever ; dengue fever; small 
pox (before the eruption); and measles. It differs from them all 
in the suddenness of its invasion ; short duration of its primary 
fever ; high temperature and pulse ; termination in a crisis ; the 
occurrence of a relapse between the third and fifth days and con- 
stant muscular and arthritic pains. 



358 



DISEASES OF THE BLOOD. 



PROGNOSIS. 

Is always good unless complications exist, the rate of mortality 
being lower than in measles. 

TREATMENT. 

This disease has been experimented upon by almost every drug 
in order to control the fever ; the decision now arrived at is that 
these patientc progress more favorably when placed under the 
best hygienic surroundings with free ventilation, a mild diet and 
?io medication whatever. During the primary fever the patient 
should be kept in bed and great care should be taken to guard 
against syncope, Should heart failure occur digitalis and stimu- 
lants must be administered. 

Test to discover Spirilloe in the blood (by Albrechs, of St. 
Petersburg). 

1st. Dry a drop of blood on a slide. 

2d. Put a drop of acetic acid on the slide which eats away the 
fibrin and blood-corpuscles, 

3d. "Wash off the slide with care so as to get rid of the dissolved 
fibrin and blood-corpuscles. 

4th. Dry the specimen and examine under the microscope, 
when the spirillse will be observed, if present 



DISEASES OF THE UEIE"AEY 
OEGASrS. 



RENAL CONGESTION. 



SYNONYM. 

Hypersemia of the kidney. 

MORBID ANATOMY. 

In active hypercemia, the kidneys may be found very much in- 
creased in size, in both the cortical or medullary portion, and this 
increase will be most marked at the base of the pyramids. The 
kidneys will be unnaturally dark in color. The capsules will be 
non-adherent, the surfaces smooth, and the organs softer and 
more moist than normal. 

On section, dark spots will be seen corresponding to the Mal- 
pighian tufts. A fluid will exude on section of the organ (half blood 
and half serum), due to oedema associated with congestion of 
the vessels. The congestion occurs in the arteries and Malpighian 
tufts before the veins are involved. The changes in the organ 
are confined to engorgement of the blood-vessels, and an infiltra- 
tion of serum into the intertubular structure in the cortical 
portion. 

In passive or mechanical hypercemia (especially when occur- 
ring in chronic cardiac disease), the kidneys are not much increased 
in size, but are of a stony-hard character and smooth. The cap- 
sules are non-adherent; their surface is smooth; and they are of 
an uniform red color. 

On section, the medullary is darker than the cortical portion. 
The Malpighian tufts are not prominent, but are simply filled 
with blood. The veins are dilated and hard; the hardness is due 
to a constant dilated condition of the efferent capillaries. There 
are not, necessarily, inflammatory changes in this form of kidney, 
but they may be accompanied by inflammation of the uriniferous 
tubes. There may be more or less change in the tubules, char- 
acteristic of simple catarrh of their lining structures. 

ETIOLOGY. 

Active congestion is produced by exposure to sudden changes; 



360 



DISEASES OF THE URINARY OltGANS. 



to blood-poisons, such as scarlatina, diphtheria, typhus fever, 
malaria; and to irritation of the urinary passages by cantharides, 
turpentine, nitre, copaiba. It may result also from diabetes, cholse- 
mia, morbid formations in the organ, traumatism, disease of the 
pelvis of the kidney, and cardiac hypertrophy (on account of an 
accelerated, or too forcible heart's action). 

Passive congestion is produced by diseases of the heart or lungs; 
mechanical obstruction in the thorax or abdomen; venous ob- 
struction to the right auricle, such as pressure on the vena cava 
above the renal vein, or on the renal vein ; arterial obstruction 
from the left ventricle; valvular lesions (especially mitral regurgi- 
tation, or tricuspid insufficiency); structural diseases of the cardiac 
walls; obstruction to the pulmonary circulation, as occurs in em- 
physema, pleuritic effusions, pneumo-thorax, fluid in the pleural 
cavity; pressure on the inferior vena cava, as occurs in pregnancy 
and abdominal tumors; mediastinal tumors pressing on the pul- 
monary artery or vein; weak heart, from exhaustion and old age; 
surgical operations on the m'ethra (from nervous causes) ; calcuU 
in the kidney ; extension of inflammation from the urethra and 
bladder; and pressure on the heart from pericardial effusions. 

SYMPTOMS. 

Decrease in the quantity of urine. 
Increase in the specific gravity. 

Albumen and traces of blood. (If albumen alone, it usually indi- 
cates inflammation.) 
Blood-casts of the urinif erous tubes (rare). 

PROGNOSIS. 

Is bad, if it occur in connection with cardiac disease, and also 
in the congestive malarial fever of hot chmates. Renal conges- 
tion may be followed by inflammation of the uriniferous tubes 
and development of Bright's disease. 

TREATMENT. 

For active liyperannia. — The patient must be kept m bed, with 
the temperature of the room about 75°. A dozen dry or wet cups 
should be applied over the lumbar region. Diluent drinks may 



RENAL HEMORRHAGE. 



361 



be freely indulged in. Administer one or two drastic purgatives, 
and avoid stimulants. Induce moderate diaphoresis. 

For passive hypercemia. — Mild counter-irritants, such as three 
or four cups, and no blisters, may be used. A brisk cathartic 
may occasionally be given, or a dose of calomel, in combination 
with some other purgative. Should there be great renal disturb- 
ance, digitalis may be given freely. If in connection with preg- 
nancy, cupping will be found serviceable. 

EENAL HEMORRHAGE. 

MORBID ANATOMY. 

The changes are much the same as those of renal congestion. 
The hemorrhage is most frequently due to embolism and 
infarction, traumatism, new- growths, or renal calculi. Con- 
gestion always takes places in the vessels which surround an 
infarction. Little masses, like ecchymotic spots, may often 
be observed in the cortical substance: and these are due to 
an effusion of blood into the uriniferous tubules, or interstitial 
tissue. On section, blood often flows freely from the uriniferous 
tubules. The seat of the hemorrhage is usually marked by the 
development of hard uniform masses in the cortical portion; these 
infarctions are wedge-shaped, with their apex toward the hilum 
of the kidney, and their base toward the surface; they may be 
capillary, and very small in size. At first they are dark-red, 
gradually becoming lighter in color. In the centre they may 
have a cheesy appearance. Changes often take place in the 
uriniferous tubes in the region of these capillaries, thus causing 
congestion and the production of lymphoid cells, which may 
undergo rapid purulent transformation, producing abscesses. 
The infarctions may increase in size, and become necrotic, pro- 
ducing gangrene. Capillary thrombi are sometimes formed, and 
may become numerous; this is due to the slowness of the capillary 
circulation. 

ETIOLOGY. 

Intense active congestion, resulting in an engorgement of the 
kidneys with blood, and rupture of the capillaries (occurring in 



362 



DISEASES OF THE URINARY ORGANS. 



scarlet, typhus, and malaria fevers ; injuries, wounds, or con- 
tusions of the kidney; cancerous development: renal, calculi in 
the pelvis of the kidney; purpura; scurvy: cardiac diseases (pro- 
ducing passive obstructive congestion); infarction (due to renal 
embolism or capillary thrombosis). 

SYMPTOMS. 

Urine. — This is the only means of ascertaining a renal hemor- 
rhage, as the blood will be effused into the uriniferous tubules 
or hilum of the kidney, and discharged into the bladder. 

If it occur from renal calculi — hemorrhage is liable to take place 
at every violent exertion. 

If it occur from cancer or tumor — it is usually profuse in quantity 
and persistent. 

If it occur from infectious diseases — it is slight, and perhaps 

only recognized by the microscope. 
If it occur from malaria — it is profuse and periodic. 
If it occur from infarction — there are chills (as it is usually due to 

pyaemia). 

PROGNOSIS. 

If it occur from renal calculi or cancer,- the prognosis will be 
bad ; if from infectious diseases, it is merely an indication of in- 
tense hyperaemia; and, if from infarction, it is always attended 
with danger. 

TREATMENT. 

The patient shotdd be kept absolutely at rest when hemorrnage 
occurs. Ice-bags should be applied to the lumbar region, and 
styptics, such as tannic acid, be given interiiaUy, as it is expelled 
through the kidneys in the form of gallic acid, if the hemoiThage 
be profuse, and there be danger of exhaustion. In some cases 
ergot may be given in large doses. If it be due to malarial 
poisoning, large doses of quinine are indicated. 

UR.EMIA. 

In this disease, the symptoms ai*e divided into two classes. 

1st. Urcemic convulsions — consisting of twitching and epilepti- 



UREMIA. 



363 



form convulsions of the voluntary muscles, ushered in by head- 
ache, nausea, and vomiting. 

2d. Urcernic coma — which is a state of insensibility, ushered in 
by headache, drowsiness, or convulsions. 

Both of these conditions are - due to failure of the kidney to 
eliminate urea, and hence accumulation of poisonous matter in 
the blood. This may occur in almost any disease. 

ETIOLOGY. 

It may be due to a complete or partial arrest of the urinary 
secretions, or to the retention of the united products of all the 
nitrogenized effete matter, usually eliminated by the kidneys; or 
to urea, which, when in excess, is an irritant poison, acting pri- 
marily on the cerebro-spinal centres, and through them interfer- 
ing more or less with the functions of organic life. 

SYMPTOMS. 

In acute urcemia. 

CEdema — in various parts of the body. 

Restlessness. 

Impaired vision. 

Headache. 

Nausea. 

Vomiting. 

Drowsiness. 

Countenance — pale, waxy, dingy appearance. 
Urine — scanty, high-colored, and bloody ; it contains albumen 
and casts. 

Violent convulsions — from excess of urea in the circulation, 
when the 

Face — becomes livid. 
Eyes— glassy. 

Pupils — contracted or dilated. 
Frothy or bloody mucus around the mouth. 
Perspiration — is of an urinous odor. 
Temperature — elevated (it may reach 107°). 
Pulse — accelerated. 
Coma — comes on gradually; resembles an attack of cerebral 



364 



DISEASES OF THE URINARY ORGANS. 



apoplexy; it may be extremely profound, or the patient 
may be easily aroused, or even return suddenly to con- 
sciousness. Attempts to speak and swallow fluids are per- 
formed with diflSculty. 
Respiration — is slow labored, and stertorous during th^ 
coma. 

Pupils — regularly dilated. 
Pulse- rapid and weak. 

Temperature— rises, and gradually falls below normal. 
In chronic ui^oemia. 

Headache — a promment symptom. 

Insomnia. 

Lassitude. 

Countenance — peculiar pallor, waxy, etc. , 
Skin — dry or moist, and has an urinous odor. 
Muscae volitantes — due often to oedema of the retina. 
Nausea. 

Vomiting— sometimes. 
Restlessness. 
Impaired digestion. 

CEdema — first about the eyes, then the ankles, and extending 

upward. 
(Edema of the lungs. 
General anasarca. 

Changes in the urine — which depend upon the type of kidney 

disease present. 
Convulsions. 

Serous inflammation— especially endocarditis and meningitis 
in the later stages. 

differeiTtial diagnosis. 

From epileptic seizure; cerebral apoplexy; ammonaemia; hys- 
terical convulsions; opium poisoning; and cholaemic convulsions. 

Epileptic seizure. 

One side convulsed more than the other. 

Loss of consciousness. Reflex sensibiUty and no rise in tem- 
perature. 
Deep sleep follows the seizure. 



URJEMIA. 



365 



UrcBmic convulsions. 

Both sides equally convulsed. 
No loss of consciousness. 
Rise in temperature. 
Deep coma follows the seizure. 

Cerebral apoplexy. 

Coma precedes the convulsions. 

Paralysis (hemiplegia) can usually be detected. 

Clonic spasms of the affected side. 

Urinary symptoms of uraemia absent. 
JJrcemic convulsions. 

Convulsions precede the coma. 

No paralysis. 

Spasms of both sides equally. 
Urine will decide the case. 

Ammoncemia. 

Urine, breath, and perspiration are all ammoniacaL 

Mucous membrane of the mouth is dry and shining. 

Sallow complexion. 

Frequent chills. 

No dropsy. 

Vomiting — rare. 

Convulsions — rare. 

Coma precedes death. 
Urcemia. 

Perspiration — has an urinous odor. 

Countenance— pale, and of a waxy appearance. 

Chills— possible. 

Dropsy. 

Vomiting. 

Convulsions. 

Hysterical convulsions. 

Patient falls (often with a scream) into a convulsive tetanic, 

or cataleptic condition 
Pupils— normal and constant blinking of eyelids. 
Temperature — normal. 
Pulse— normal. 



366 DISEASES OF THE URINARY ORGANS. 

Limbs — jerked irregularly . 
No lividity of the countenance. 

Breathing — spasmodic, and a choking sensation is often com- 
plained of. 

Discharge of large quantity of pale urine after the attack, 
Uroemic convulsions. 

Convulsions are preceded by headache, etc. 
Pupils — regularly dilated, or contracted. 
Temperature - accelerated. 
Pulse — accelerated. 
Jerking is regular. 
Countenance — livid.- 

Respiration — labored, slow, and stertorous. 
Urine— will decide the case. 

Opium poisoning. 

Temperature — usually "below normal. 

Respiration — slow and regular. 

Pupils— uniformly contracted (pin-point pupils). 
Uroemic coma. 

Temperature — elevated 100°. 

Respiration — slow, labored, and stertorous. 

Pupils — uniformly dilated. 
Cholcemic convulsions. 

Produced from overcharge of bile in the blood. 

The convulsions are preceded or accompanied by jaundice. 

CAUSES OF DEATH. 
Death results from the action of urea on, and overwhelming of,, 
the nerve-centres, producing changes in the blood, which. inter- 
fere and arrest oxygenation; there are then structural changes 
taking place in the tissues, rendering them incapable of support- 
ing life. 

PROGNOSIS. 

Depends upon the amount of urea in the blood, and the time it 
has been accumulating. 



BRIGHT'S DISEASE. 



367 



TREATMENT. 

The patient should have absolute rest and free elimination, pro- 
cured either by the skin or bowels, or both. Diaplioresis may be 
accomplished with hot-air baths. Drastic purgatives, as elate- 
rium, scammony, or croton oil, may be administered. Digitalis 
is the best diuretic that can be given; it strengthens the heart's 
action and the eliminating power of the kidneys, since the blood- 
pressure is increased. Inf. of English leaves, dose § ss. , may be 
taken every three hours for the first twenty-four hours, or until 
the specific effect of the drug is produced. For ursemic convul- 
sions, morphine should be administered hypodermically ; vi x. at 
first, and if that does not arrest them, give tt^, xx. every two hours, 
to control the convulsions. It arrests the muspular spasm by 
counter-acting the effect of the uraemic poison on the nerve- 
centres, and establishes diaphoresis, and it further facilitates the 
diuretic action of digitalis. 

BRIGHT'S DISEASE. 

The three distinct elements which are primarily or secondarily • 
involved in the morbid changes of the kidney are (1) the urinifer- 
ous tubules; (2) the blood-vessels dn the walls); and (3) the inter- 
tubular connective-tissue. 

The various forms of Bright's disease may be classified under 
three heads (from a pathological basis), as follows: 

1. Those which are inflammatory in their nature, and com- 
mence in the uriniferous tubules, designated as "parenchymatous 
nephritis.''' 

2. Those which are non-inflammatory in their nature, and com- 
mence in the walls of the blood-vessels, designated as the * ' amy- 
loid variety,''' 

3. Where the changes commence in the intertubular tissue, 
designated as the cirrhotic type." 

PARENCHYMATOUS NEPHRITIS. 

This is the most common form, and is of an inflammatory 
nature. It may be of either short or long duration, and may. 



368 



DISEASES OF THE URINARY ORGANS. 



therefore, be subdivided into the acute and chronic form. It has 
three stages. 

STAGES. 

1st Stage. Active inflammation — called "acute desquamative 
tubular nephritis," or " acute parenchymatous nephritis." 

2d Stage. Degeneration— which may be either fatty or gi-anular, 
and is called by some authors the ''fatty'' or " large white kid- 
ney.'" 

8d Stage. Atrophy of the organ. 

MORBID ANATOIMY. 

First stage (inflammation). — This may be either catarrhal, 
croupous, or desquamative in type. The kidneys are increased in 
size; their capsules are non-adherent; their surfaces are smooth 
or mottled; they are usually of a dark and purplish color, dotted 
with spots of ecchymosis, and are firm on pressure. 

On longitudinal section of the organ. — The cortical portion is 
seen to be increased in volume and dotted over with dark or red 
spots, which correspond to the congested Malpighian tufts. The 
cortical substance betv^reen the tufts may be paler than normal. 
There will usually be engorgement, well-marked at the base of the 
pyramids (at the junction of the cortical and meduUary portion); 
the meduUary portion will be darker than normal, with alter- 
nating red and white lines (the light lines denote changes in the 
uriniferous tubes). The lining membrane of the pelvis is some- 
what congested. The well-marked engorgement at the base of 
the pyramids exists, on account of the venous arcades being situ- 
ated over the base of each pyramid. 

On microscopical examination, the tubules will be found to 
be the seat of a simple catarrhal process. The epithelial lining 
may be partially or completely lifted, and may have disappeared, 
while the tubules may be more or less filled with cells correspond- 
ing to new cell- formation (a simple catarrhal inflammation). The 
centre of the tubes may also contain a hyaline material (which is 
coagulated fibrin), or this hyaline material may be surrounded by 
epithelium and blood-globules. (It is an inflammatory exudation, 
resembling that of croupous inflaiamation elsewhere.) These 



PARENCHYMATOUS NEPHRITIS. 



369 



changes usually commence in the epithelial cells of the tubes; 
the cells become cloudy; their nuclei disappear; they become 
distended and granular; and, finally these changes are followed 
by desquamation. The tubes may thus be filled with broken- 
down epithelium and fatty matter (the latter condition indicating 
chronic desquamative nephritis). In the first stage of the inflam- 
matory variety you may have one or all of these conditions pres- 
ent in the uriniferous tubules, and also new cell-formation in the 
in the intertubular tissue. 

Second stage (fatty or granular kidney). — This is described by 
some authors as a special type of kidney. The kidneys are en- 
larged; the capsules non-adherent; the surfaces smooth; the 
organ paler in color and softer than normal (when fatty degener- 
ation is going on), and presenting a yellow or mottled appearance. 
The enlargement is due to an increase in volume of the cortical 
substance (as shown on section of the kidney\ which is of a pale 
yellowish-white color. Under the microscope, the organ shows 
more or less fat in the tubes, and a diminished vascularity of the 
kiUney. The changes occur chiefly in the convoluted tubes of 
the cortical substance adjoining the Malpighian bodies. The 
tubules are distended with oil-globules, and large hyaline casts 
may be found in them. Atrophy, or granular degeneration of 
the kidney follows (if the circulation and nutrition of the 
organ be interfered with) since this stage is associated with, or the 
result of long-continued active or passive renal congestion. 

Third stage. — After the transformation (fatty) of the epithelial 
elements in the second stage, cellular elements are developed in 
the walls of the tubes and intertubular tissue. Organization and 
contraction of this new connective-tissue occurs, compressing the 
blood-vessels. The tubules thicken, and atrophy of the kidney 
substance, together with fatty and granular degeneration of the 
contents of the tubules and the epithelium, is developed. 

The microscope in this stage shows excessive development of 
the new connective-tissue and constriction of the tubules, causing 
development of cysts. The kidneys are uneven and nodular, and 
smaller and harder than normal; the capsule is tliickened and 
adherent, and, when removed, tears off part of the kidney. The 



370 



DISEASES OF THE URINARY ORGANS. 



cortical substance will be seen to be decreased, and sometimes to 
have almost disappeared; the tubes have collapsed, and cysts are 
found to have developed. The principal changes are thickening 
of the walls of the blood-vessels; more or less obliteration of the 
uriniferous tubules, and disappearance of the epithelial lining; 
evidences of a previous fatty and granular degeneration, and a 
marked increase in the walls of the tubules and the capsules of 
the Malpighian tufts. 

In summary, the following changes may thus be said to take 
place in the several stages of this form of nephritis (the inflam- 
matory form): 

1. There may be more or less intense congestion, with very 
active proliferation and desquamation of the epithelium, which 
lines the tubules (causing the tubes to be blocked up and dis- 
tended). 

2. This excessive engorgement may produce a rupture of the 
capillary vessels and an escape of blood-globules into the tubes, 
and an effusion of fibrin from the interrupted circulation. This 
latter exu(Jation coagulates in the tubes, and mixes with the epi- 
thelial cells and blood-globules (hyaline material). 

3. The contents of the tubules (epithelial cells) become the seat 
of a fatty degenerative process. Their nuclei soon disappear, 
and the tubules become distended and filled with a mass consist- 
ing of broken-down epithelium matter and fat. 

ETIOLOGY. 

PREDISPOSING CAUSES. 

From exposure to sudden changes; from alcohol, ^' going on a 
spree," and sitting in a draught; from irritation and inflammation 
of the uriniferous tubules, produced through excessive labor of the 
kidneys to throw off the accumulated excrementitious material (the 
power of elimination being arrested through the defective action of 
the skin); from inflammation due to reflex influence of the nervous 
system; from additional work and some peculiar shock through 
the sympathetic; from renal hyperaemia, and its various causes; 
from inflammation of other organs. 



PARENCHYMATOUS NEPHRITIS. 



371 



EXCITING CAUSES. 

(1) Blood-poisoning (as evidenced in the renal hyperaemia follow- 
ing fevers, scarlatina, typhus, diphtheria, measles, pyaemia, rheu- 
matism; and in the direct irritation of the tubuli uriniferi, fol- 
lowing the use of copaiba, turpentine, cantharides, etc.); (2) 
mechanical interference with the circulation of the ki(^ney, as 
occurs in pregnancy and cardiac diseases; (3) senile decay, pneu- 
monia, extension of inflammation from adjacent structures, etc. 

SYMPTOMS. 

In the mild form, or simple catarrh of the uriniferous tubules. 
(Edema of the face. 

(Edema of the feet and ankles (occurs early if heart lesions 

exist). 
Eestlessness. 

Headache — constant and increasing (due to irritating effects 

of the accumulated urea). 
Urine— scanty, high-colored, and of high specific gravity. 
Frequent micturition (if the bladder experiences irritation). 
Nausea, 



Vomiting, 



evidences of the poisonous effects of urea. 



Perspiration — has an urinous odor (if the poisoning by urea be 
rapid). 

Pain — in the back and loins. 
^^Drowsiness. 
Dry skin. 

Pulse — accelerated and irritable — firm and hard. 
Rise in temperature (denoting fever). 
As a severe type develops from a mild form. 
(Edema - all over the body. 
Pulmonary congestion. 

Expectoration— watery, streaked with blood. 

Dyspnoea— (from pulmonary oedema, or uraemia affecting the 

respiratory centres). 
Countenance — pale and waxy. 

"Water-logged condition (the dropsy accumulating gradually 
as the case goes on). 



372 



DISEASES OF THE URINARY ORGANS. 



CEdema of the scrotum and penis — (from blood-poisoning). 
Great restlessness— (from blood-poisoning of nerve-centres). 
Muscular twitchings — (from blood-poison of motor centres). 
Convulsions — from the blood-poison, creating irritation of the 

cortex, or from pressure of oedema. 
Coma — from the blood-poison acting upon the nerve-centres 

to a marked extent. 
Death — from the blood-poison, creating oedema of lungs, 
heart complications, meningeal inflammation, etc. 
In the chronic variety. 

If commencing with an acute type, the follov^ing symptoms 
may be developed : 
General anasarca. 
Pulmonary oedema. 

Countenance — pale and waxy (like cancer). 
Urine — passed in large quantities. 

Appetite returns, ^ as the symptoms of acute iircemia 

Nausea— disappears, I subside, and the disease assumes 

Restlessness — disappears, [ a less active form of blooJ.-poi- 
Sleep becomes refreshing, J soning. 

The patient is thus passing on to the third stage, and becomes 
a more or less confirmed invalid. 

(Edema of the feet is always present (to a greater or less de- 
gree). 

Cardiac hypertrophy develops (on account of changes in the 
capillary vessels, and from poor nutrition to the heart, 
which necessitates an increase of size to insure the nor- 
mal power of that organ). 
In very acute cases — uraemia may be ushered in by 

ChiUs. 

Temperature — markedly elevated, 106°. 

Pain — well marked along the back and ureters. 

Marked oedema of the face. 

Urine — completely suppressed or greatly diminislied in quan- 
tity, or even bloody. 
Nervous system — disturbed to a marked degree. 



PARENCHYMATOUS NEPHRITIS. 



373 



Testicles— retracted (if the kidneys be excessively irritated, 

even if a calculus be not present). 
Delirium. 

Coma — will probably develop rapidly. 

Death may result in two or three days. 
The main cause to which most of these symptoms may be at- 
tributed is urea, in abnormal quantities in the blood (producing 
the phenomena which attend the development of the different 
forms). 

The principal symptoms that always present themselves for 
consideration are those in connection with the changes in the 
urine, the development of dropsy, and the nervous phenomena. 
These may be thus hastily summarized: 

Urine. 
In the First Stage. 
{Stage of congestion and exudation in the uriniferous tubules). 
Scanty and high-colored. 
High specific gravity (1.080). 

Albumen (usually about one-half of the specimen examined). 
Casts— epithelial, small hyaline, blood-casts, and blood-glob- 
ules. 

In the Second Stage. 
(Stage of exudation and fatty degeneration). 
More abundant. 
Not so highly colored. 
Lower specific gravity (1.005). 

Albumen (usually about one-third of the specimen examined). 
Casts— oil-globules and fatty, in addition to those in the first 
stage. 

In the Third Stage. 
{Stage of degeneration and atrophy). 
Greatly increased, and becomes pale. 
Specific gravity usually about 1.010. 
Albumen — (very slight quantity, if any). 
Casts — fine granular and large hyaline. — - 



374 



DISEASES OF THE URIXAHY ORGANS. 



may be developed if the poisoning be gradual. 



Dropsy. 

Is caused by the excess of urea acting upon the capillaries and 
composition of blood. It can thus be explained- 

(1) by hydraemia, and 

(2) by imperfect nutrition of the heart (when there is first hy- 
pertrophy, and then softening). 

Nervous Phenomena. 
Are caused by the urea inducing toxic symptoms. 
Headache, if constant, is a dangerous symptom, and of great 
importance, as it is apt to indicate the possibility of convulsions. 
Drowsiness, 
Stupor, 
Nausea, 
Vomiting, 
Fever, 

Convulsions, 
Coma, 

Death results from the effects of urea upon the nervous system, 
or from some of the complications of ursemic poisoning. 

Theories for Convulsions. 

1. Urea in excess in the blood (which poisons the nerve-centres 
directly). 

2. (Edema of the medulla (causing pressure upon it). 

3. Urea becomes an active poison by being changed into am- 
monium carbonate (which causes irritation to the nerve-centres). 

Urcemic convulsions usually come on in the manner herein in- 
dicated. Great neiwous prostration will probably have previously 
existed, as well as headache and musc« vohtantes; sudden stiffen- 
ing of the muscles; eyes, rolled up and fixed; head, turned to one 
side; teeth, tightly clenched; countenance, becomes livid; in- 
spirations, long and deep; muscular twitchings; profound sleep; 
tongue, may be bitten, or, fall back on the epiglottis, closing the 
larynx, and thus produce death. 

To determine the quantity of solid matter excreted daily. 

Multiply the two last figures of the specific gravity of the urine by 
the number of ounces passed by the patient during the twenty -four 
hours, and the result will be the quantity of sohd matter excreted 



PAREXCHYMATOUS NEPHRITIS. 



375 



in the urine (in grains). Five hundred grains of urea being the 
normal quantity excreted daily in health. 

It is estimated that from six hundred to one thousand and 
twenty grains of solid matter are excreted daily by a healthy in- 
dividual ; and 25 to 80 fluid ounces of urine passed daily. 

CAUSES OF DEATH. 
Death may be due to uraemia; meningitis; peri- and endo-carditis; 
or pneumonia. 

COMPLICATIONS. 
Cardiac hypertrophy may occur in the chronic form of Bright's 
disease, and is due to interference with the systemic circula- 
tion from long-continued excess of urea. 
In the lungs and bronchi. 

Pulmonary oedema — may develop m the first stage, or is one 

of the results of a general dropsy. 
Pneumonia — if developing in connection with pulmonary 

oedema, and if albumen and casts be found in the urine, 

offers an unfavorable prognosis. 
Bronchitis — This may occur as a complication of Bright's, 

with or without pulmonary oedema. 
Fluid in the pleura, in the latter stages of Bright's disease, 

may occur as an evidence of serous inflanunation, or of 

general anasarca. 
Endocarditis — (from the irritating influence of poison) may 

exist as one of the serious complications of Bright's dis- 
ease. 

Meningitis — (as another serious complication) may be devel- 
oped as a result of ursemic poisoning. 

Subacute inflammation of the mucous membrane of the 
stomach (structural changes). 

Amaurosis or neuro-retinitis (loss of sight). 

Erysipelas — from poisoning of the nerve-centres, or from a 
defective nutrition of the tissues. 

Gangrene— from pressure on the vessels by the oedema (cut- 
ting off the nutrition); from changes in the capillaries 
(which interfere with the circulation of the part); from 



376 



DISEASES OF THE URINARY ORGANS. 



defective heart-power (causing poor nutrition); and from 
the direct effects of the poisoned condition of the blood. 

DIFFERENTIAL DIAGNOSIS. 
From typhus fever and the amyloid and cirrhotic forms of kid- 
ney disease. 

PROGNOSIS. 

Is bad as .regards complete recovery. In the first stage, the 
prognosis varies with the character and intensity of the inflamma- 
tory process. In nearly every instance, the catarrhal or croupous 
forms may be recovered from. If with the croupous variety de- 
generation and desquamation go on slowly complete recover}- is 
rare. 

In the second stage (fatty) the chances for a complete recovery 
are very doubtful, if this stage has been reached by epitheUal de- 
generation, and evidences of extensive obstruction in the tubules 
exist, the stage of granular degeneration and atrophy are sure 
to f oUow. 

TREATMENT. 

In the Fii'st or Inflammatory Stage. 

1. Eliminate the urea. 

2. Remove the inflammatory products in the uriniferous tubules. 

8. Counteract the effect of the urea on the nervous system. 

First, remove the exudation in the tubules (which develops de- 
generative inflammation). Digitalis must be given, as it increases 
the secretions, and does not stimulate the kidneys; it also increases 
the power of the heart's action, and overcomes the obstruction in 
the renal circulation, causing an increased flow through the Mal- 
pighian tufts in the upper portion of the uriniferous tubules. It 
should be given in large doses. Inf. dig., 1 ss. every two hours for 
twenty-four hours, and wait twelve hours, and watch it, then 
give smaller doses ( 3 i.), and stop as soon as you have good diure- 
sis. Dry cups should be applied over the region of the kidney, in 
conjunction with digitalis; it draws the blood to the surface, 
but does not cause extravasaticni. Then ap[)ly warm poultices 
made of digitalis leaves. Temporary J tot bath and hydragogue 
cathartic may be resoi!;ed to if the urfemic symptoms axe rr<?:f>ri^. 



AMYLOID KIDNEY. 



377 



Oleum tiglii, (oleum erotoni) (but not after free diuresis has 
been obtained). In case of the following symptoms occurring, as 
headache, vertigo, restlessness, convulsions, and coma, the treat- 
ment for acute uraemia should be followed (see page 367). Then 
actual cautery may be applied over the lumbar region ; it acts on 
the sympathetic nerves, and causes contraction of the renal blood- 
vessels. Depletion should only be used in the first stage of 
Bright's, and the form which follows pregnancy, surgery on 
genito-urinary tract, and exposure. 
In the Second or Degenerative Stage. 

Administer digitalis in moderate doses, and thus remove the 
fatty accumulations from the tubules. Iron should be given with 
a most nutritious diet. The patient should be fed on about half 
a pint to a pint of milk at a time, consuming about three to four 
quarts in the twenty-four hours. Moderate stimulants, such as 
wines, may be given. The patient must have the best hygienic 
surroundings, be kept in a well- ventilated department, with an 
uniform temperature, and the body be covered v/ith flannel. Re- 
covery may take place in about six weeks, if no tubular degenera- 
tive process commences. 
In the Third or Atrophic Stage. 

Diuretics are not required; a supporting plan of treatment is 
indicated. Food should be given in small quantities, and often, 
and let them have cod-liver oil and iron. Wines should be ad- 
ministered in moderation. Cover the body with flannel, and do 
not expose it to sudden changes in temperature; or send the 
patient to a warm climate. Should the urine become scanty, give 
two or three full doses of digitalis, to prevent acute tubular 
nephritic inflammation. 



AMYLOID KIDNEY. 
DEFINITION. 

Is a non-inflammatory condition of the kidney, which com- 
mences as a deposit of amyloid material in the walls of the blood- 



378 



DISEASES OF THE URINARY ORGANS. 



vessels. It is always chronic in its course, and usually invades 
several organs at the same time. 

MORBID ANATOMY. 

The minute arteries are first affected; then changes occm* in the 
secreting tubes, or cells; and, finally, atrophy of the organ itself 
ta,kes place. It has three stages. 

1st Stage. Degeneration of the walls of the blood-vessels. 

2d Stage. Changes in the blood-vessels and the urinif erous tubes. 

3d Stage. Atrophy of the organ. 

In the First Stage. — (Degeneration of the walls of the blood- 
vessels). The kidney is slightly increased in size and firmer than 
normal. The capsule is readily removed, and the surface is 
smooth and paler than normal. 

071 section. — If Lugol's solution of iodine be applied, with a 
clean camel's-hair brush, over the suspected portion, in a few 
seconds, if amyloid material be present, the affected part rapidly 
absorbs the iodine, and results in a dark-brown tint which is 
easily distinguished from the yellow stain of the non diseased 
tissue. There are glistening streaks along the course of the blood- 
vessels, and especially in dots corresponding to the Malpighian 
tufts. These glistening portions of the organ give the blue re- 
action to the iodine and the svilphuric acid tests. 

Microscope. — Shows the changes to be most marked in the Mal- 
pighian tufts, and that the middle coat of the small arteries has 
undergone more or less alteration from a deposit of amyloid ma- 
terial, and are irregular in outline. This irregularity of outline 
is due to the amyloid deposit in the coats of the blood-vessels. 

In the second stage. The kidney is very much increased in size , 
the capsule is adherent ; and the surface pale and smooth and pre- 
sents a steUate vascularity, 

On section. — The increase in the size of the organ is seen to be 
due to an increased development in the cortical substance. The 
blood-vessels have undergone a waxy change, and the whole kid- 
ney has a waxy appearance. 

The microscope shows the entire surface to have a shining, waxy 
appearance. The tubules in the medullary substance are dis- 



AMYLOID KIDNEY. 



379 



tended with a substance similar to that found in the coats of the 
blood-vessels (but does not respond to the iodine test). This sub- 
stance may be broken-down epithelium and fatty granules, or 
fibrinous material, like hyaline casts. The Malpighian capillaries 
are thickened, opaque, and glistening, and there is degeneration 
of the larger blood-vessels. The casts are chiefly in the large 
tubes of the pyramids. 
In the TJiird Stage.— (Atrophy.) 

On section. — The size of the kidney is diminished; the capsule 
adherent; the surface uneven, pale, and waxy. There is a 
diminution in the size of the kidney (due to a decrease of both 
the medullary and cortical substance). The Malpighian tufts are 
large and prominent. The small arteries are enlarged; their walls 
are impervious; and their circulation obstructed. 

TliQ microscope shows the tubules to be more or less atrophied, 
and their walls collapsed. The blood vessels are thickened and 
irregular in outline. The iodine test decides the nature of the 
change. 

ETIOLOGY. 

Tertiary syphilis; prolonged suppuration (especially in diseases 
of the bone); suppurative diseases of the lungs (empyema, phthi- 
sis). 

SYMPTOMS. 

General emaciation (from some wasting disease). 
Impaired mental faculties, and, possibly, insomnia. 
CEdema of the feet at night. 

Dyspnoea — on exertion (probably due to anaemia). 

Complexion— pale and waxy (often with pigment in the eyelids), 

A sense of fullness and weight in the abdomen. 

Urine — increased ; patient rises two or three times in the night to 

micturate. 
General anasarca — may occur. 
Perspiration— has an urinous odor. 
Dyspepsia. 
Nausea. 
Vomiting. 



880 



DISEASES OF THE URINARY ORGANS. 



Spleen — enlarged. 

Liver — enlarged, with smooth, sharp edges (due to amyloid 

changes). 
Cachexia. 

CAUSES OF DEATH. 

Death may occur from exhaustion (more frequently from amy- 
loid degeneration of other organs) ; from diarrhoea (due to amyloid 
degeneration of the mucous membrane of the intestines); and 
from ascites (due to changes in the liver). 

If dyspeptic symptoms do not yield to treatment, and you have 
also enlarged liver and spleen and diarrhoea, it is beyond a doubt 
that amyloid degeneration of the intestines has caused death. 

The prmcipal symptoms that have to be borne in mind are those 
in connection with the urine, the development of slight dropsy, 
and the absence of marked nervous phenomena. 

Urine. 

Increased in quantity — may reach one hundred ounces in twenty- 
four hours. Forty ounces in twenty-four hours is a small 
quantity. It is of a light color, like clear water, or slightly 
amber. Low specific gravity (loOOS). 

Albumen — not large in quantity (only a trace may often be de- 
tected); if large in quantity, it shows that tubular inflamma- 
mation has occurred in a degenerated kidney. 

Casts — large hyaline or granular, or both, but not abundant; epi- 
thelial or fatty casts may also be detected (showing inflam- 
matory process of the tubules). 

Dropsy. 

Is never very marked. 

(Edema— of the feet at night, probably due to changes in the liver. 

Nervous Phenomena. 
Rarely headache, convulsions, or coma. 

DIFFERENTIAL DIAGNOSIS. 
Is easy; for, if from the commencement of the disease there 
has been a copious secretion of urine, of low specific gravity, con- 
taining little albumen, and the symptoms of the disease have 
come on gradually in one who is suftering from an exhaustive 



CIRRHOTIC KIDNEY. 



381 



disease, you may expect to find amyloid kidneys. The probabili- 
ties are that the kidneys will be increased in size, if the liver and 
spleen are found to be enlarged. 

PROGNOSIS. 

The duration of life is uncertain. It usually takes years to 
establish the disease, but, when once established, is fatal. 

TREATMENT. 

If possible, remove the cause, as it occurs in the diseases of the 
bone, suppuration, etc.; therefore, remove the purulent accumu- 
lations. If occurring from tertiary syphilis, use antisyphilitic 
remedies, as iodide of potassium and mercury. Mercury should 
be given in small doses, and often (but do not produce ptyalism); 
but when debility exists, give iodide of potassium and cod-liver 
oil. Iodide of iron may be given in the form of Blanchard's 
pills; give one three times a day when taking food. Hydragogue 
cathartics and diuretics are of no service, excepting when the in- 
flammatory form exist, then resort to dry cups, etc. 

OIERHOTIO KIDNEY. 
SYNONYMS. 

"Gin-drinkers' kidney;" granular kidney; contracted, or "hob- 
nailed" kidney. 

DEFINITION. 

Is due to an increase in the intertubular structure, and an 
atrophy of all the other structures. 

STAGES. 

1st Stage. Enlargement — due to an increase in the intertubular 
tissue (from connective -tissue cell-growth). 
2d Stage. Organization of this new tissue. 

3d Stage. Atrophy — due to contraction of this new tissue (pro- 
ducing degeneration, on account of pressure on the blood-vessels 
of the organ). 



382 



DISEASES OF THE URINARY ORGANS. 



MORBID ANATOMY. 

As the process progresses, there is shrinking of the kidney tis- 
sues. The kidney is diminished in size, the capsule thickened and 
adherent, and there is a prolongation of the connective-tissue into 
the cortical substance, causing removal of the structure when the 
capsule is torn off. Dilated veins may often be seen on the sur- 
face. The diminution in the size of the organ is due to a decrease 
in the coi-tical substance. The medullary substance retains the 
same appearance as normal, and is not diminished. There may 
be cysts near the surface on the cortical substance (if the tubes 
be obliterated, and the tufts of Malpighi continue to secrete). 

In the first stage. — The microscope shows an increase in the 
connective-tissue between the Malpighian tufts and the urin- 
iferous tubules. The kidney is slightly increased at first, and 
then shrinks; the Malpighian tufts are diminished; the urinifer- 
ous tubules are obliterated by contraction of the new connectiva- 
tissue; the capsule is thickened, firm, and fibrous. The arteries 
are hypertrophied and irregular; the tufts are brought nearer to- 
gether by the increase in the connective-tissue, and are sometimes 
obliterated by cysts. The tubules may contain coagulated fibrin, 
which is indicated by hyaline casts in the urine. The changes are 
due to hyperaemia. Some say the inflammation is due to alcohol 
or gouty diathesis; if due to the latter, there is, in addition to the 
intertubular changes, a deposit of urates of soda in the cortical 
substance and apices of the cones. 

The inflammatory process is the only cause of the anatomical 
changes in the organ. 

ETIOLOGY. 

The two most common causes are rheumatism and gout, pro- 
ducing gouty kidney (due to a change in the blood from these 
diseases); lead-poisoning, cancerous diathesis, and alcoholism, 
may produce, at the same time, cirrhosis, both of the fiver anc" 
kidney. 

SYMPTOMS. 
Are obscure, and its approach is insidious, 
frequent micturition is usually present. 



CIRRHOTIC KIDNEY. 



383 



TJrine — may not contain albumen nor casts. 
Dropsy — may not occur. 

Nervous symptoms may be the only well-defined ones. 
The usual symptoms are 

Debility. 

Emaciation. 

Dyspepsia. 

Great thirst. 

Urine— is very large in quantity. 
Complexion — is of a dingy hue. 

CEdema — slight, and usually confined to the lower extremi- 
ties, after standing or walking. It is more marked at 
night than on rising in the morning. 

Expression — care-worn. The patient often becomes fretful. 

Nervousness. 

Eestlessness. 

Insomnia (a prominent symptom in some cases). 
Convulsions. 

Coma— (for twenty-four hours or more before death). 
Death. 

The principal symptoms that have to be borne in mind are those 
in connection with the urine, the dropsy, and the nervous phe- 
nomena. 

Urine. 

Increased in quantity. 

Low specific gravity (1.010). 

Albumen— sometimes present, but inconstant. 

Casts — usually large hyaline. They are often difficult to find, 

and may not be observed until three or four examinations 

have been made. 

Dropsy. 

OEdema — slight, and usually confined to the feet, after exercise or 
standing; but, if it become chronic in the feet, it is asso- 
ciated with general symptoms. 

Ascites - may occur from changes in the liver. 



384 



DISEASES OF THE URINARY ORGANS. 



Nervous Phenomena. 
Headache — most prominent if associated with gout and rheuma- 
matism. 

Vertigo. — High arterial pressure marked at radial pulse. 

Temporary inability to speak may exist in some instances. 

Amaurosis. 

Deafness. 

Numbness. 

Neuralgic pains. 

Cramps. 

Delirium or insanity. 

Insomnia — (great, and extending over a long period of time). 
Paralysis — (temporary, and partial in the arm or leg). 
Convulsions— (usually developed after some mental or physical 
exertion). 

Coma— which may follow a condition of drowsiness, or deliriimi» 
Tongue — dark-brown. 
Pupils— dilated (if coma exist). 
Death. 

CAUSES OF DEATH. 
Death usually takes place from convulsions, preceded by head- 
ache, and terminating in coma. 

COMPLICATIONS. 
Cardiac hypertrophy of the left ventricle — usually occurs from 
disease, atheroma, or calcareous degeneration of the walls of the 
large, arteries. 

If cardiac hyperti'ophy of the left ventricle exist, and the urine 
be abundant, of low specific gravity, and containing only a trace 
of albumen, it is sufficient to establish the diagnosis of cirrhotic 
kidney. 

Mucous inflammations, especially bronchitis (of the chronic 
type), alternating with renal and gouty symptoms. 

Amaurosis (of uraemic origin), called neuro-retinitis (first of one 
eye, then of the other). 

Hemorrhage from serous and mucous surfaces, as well as in the 
substance of the organs. Cerebral hemorrhage is especially liable 



PYELITIS. 



385 



to occur (cerebral apoplexy) from degeneration of the cerebral 
arteries, and an increased force of blood from an hypertrophied 
left ventricle (thus causing rupture of the capillaries). 

DIFFERENTIAL DIAGNOSIS. 

(1) From typhus fever, on account of the uraemic stupor and 
dry tongue. In typhus fever, however, there will be the erup- 
tion, and the quantity of urine passed may serve as a guide in the 
diagnosis. 

(2) From gouty and rheumatic diathesis. In this there will be 
the history. The low specific gravity and profuse quantity of 
urine (which may contain albumen and casts) is sufiB.cient to es- 
tablish a diagnosis of cirrhotic kidney. 

PROGNOSIS. 

Is bad as regards recovery. 

TREATMENT. 

Hydragogue cathartics should be given when the disease is de- 
veloped, in connection with cirrhosis of the liver. Resulting, as 
this disease usually does, from rheumatism or gout, and the 
patient suffering from headache, restlessness, nervous and trem- 
ulous affections, it is advisable to send this class of patients to 
the alkaline springs, as you would in cases of rheumatism or 
gout, and administer bicarbonate of soda and potash in large 
doses. Iron is not desirable, as it has too great an effect on the 
nervous system. Strychnia is preferable to iron, and should be 
given in minute doses for a long period. In many cases cod-liver 
oil should be combined with the hypophosphate of soda. These 
patients should reside permanently in a warm climate, all exciting 
causes of cirrhotic development should be avoided, and hygienic 
rules must be carefully observed. JVever give digitalis or iron. 

PYELITIS. 
DEFINITION. 

Is an inflammation of the mucous membrane of the pelvis and 
calices of the kidney. It may be acute or chronic in its course. 



386 DISEASES OF THE URINARY ORGANS. 

MORBID ANATOMY. 
In the acute variety. — The mucous membrane of the pelvis is 
more or less congested. The surface is dotted with red spots 
(ecchymosisj. The epithelial covering is more or less removed 
(may be entirely destroyed, or absent in patches). There is usu- 
ally a muco-purulent secretion covering the surface of the mucous 
, membrane. There may be a diphtheritic membranous exudation 
on the surface of the mucous membrane, which is due to a gene- 
ral diphtheria. 

In the chronic variety, — The mucous membrane of the pelvis 
of the kidney is not only much thickened, but changed in color. 
It may be grayish-white or slate-colored, and traversed with 
dilated veins. The pelvis and infundibula are dilated. Pus is 
abundantly formed, and, if not obstructed, flows off with the 
urine; but, if there be obstruction, it accumulates and produces 
pyonephrosis. The accumulation of pus causes the papillae to 
become flattened and obliterated. Then the pyramids are com- 
pressed, and, lastly, the cortical substance, both of which may 
eventually disappear on account of pressure. The sac so formed 
contains pus, broken-down material, or calcareous matter. If 
pyelitis be caused by obstruction from renal calculi, there may be 
ulceration of the mucous membrane, causing perforation of the 
pelvis and extravasation of urine into the adjacent tissues. The 
ureters may be the seat of disease, from an extension of pyelitis, 
and may be obstructed by pus, blood, and urinous material, pro- 
ducing a sac, like an abscess, which may be evacuated by an 
opening into the adjacent tissues. Inflammation may be estab- 
lished, and the pus may be discharged externally (by ulceration), 
or into the intestines. The accumulation may occasionally un- 
dergo absorption, transforming the ureters into a tendinous cord; 
in this case, the other kidney has to do double work. 

ETIOLOGY. 

Calculi, or any foreign body or substance in the pelvis of the 
kidney, may create it; and irritation (by decomposition of urine 
in the pelvis of the kidney) may prove an oxciting cause. Ure- 
thral stricture or enlarged prostate (by causing retention, after- 



PYELITIS. 



387 



ward cystitis, and inflammation of the mucous membrane, ex- 
tending to the ureters) may create it. The lining of the ureters 
thus becomes thickened, and their calibre diminished, obstructing 
the flow from the kidney. The retention of urine in the bladder 
and the pelvis of the kidney causes a decomposition of urea into 
ammonium carbonate and water. The ammonium carbonate 
produces irritation, which induces inflammation of the lining 
membrane of the bladder and kidney (cystitis and pyelitis), or 
ammonaemia (from absorption of ammonia). Finally, blood- 
poisoning (of all forms); acute parenchymatous nephritis, with 
bloody urine ; and overdoses of turpentine, cantharides, and other 
stimulating diuretics, may be mentioned as causes of pyelitis. It 
may be secondary to morbid processes, or to mechanical irrita- 
tion, and occasionally follows exposure to cold or dampness. 

SYMPTOMS. 

Are modified by the causes which produce it, such as renal cal- 
culi, bladder diseases, etc. , etc. 

^cute Pyelitis. 

Pain— in the back, always over one or both lumbar regions. 
It is usually aching in character, shooting down the 
course of the ureters. It occurs with micturition, and is 
incessant if micturition be excessive. It is also aggra- 
vated by exertion or change of position. 

Urine— is usually acid, and contains blood mixed with mucus 
and epithelial-cells, pus-cells, and blood-globules (the epi- 
thelial-cells are of the type which normally exist in the 
pelvis and infundibula). Epithelial-cells denote an early 
stage of the disease. Specific gravity 1.025 to 1.030. 

Is ammoniacal in the advanced stages, and often contains 
albumen. 

If there be obstruction, the urine from the other kidney is 
normal. If the obstruction be removed, the urine may 
suddenly become purulent, and continue to be so. 
Chronic Pyelitis. 

Tumor — in the lumbar region. 

Bulging between the crest of the ilium and the false ribs. 



388 



DISEASES OF THE URINARY ORGANS. 



Ureters — completely obstructed. 

Accumulation of fluid in the pelvis of the kidney. 

Palpation — shows deep-seated fluctuation. Ihe tumor is 
painful and tender on pressure. 

Percussion — elicits a dullness whose limits depend on the out- 
line of the tumor. 

DIFFERENTIAL DIAGNOSIS. 
From cystitis and peri-nephritic abscess. 

In pyelitis, associated with chronic cystitis, or enlarged prostate, 
or stricture (should the pus be large in quantity, the urine slightly 
cid, the loin painful, and constant febrile movement and emaci- 
ation exist), it indicates chronic pyelitis. 
In acute Pyelitis. 

Urine — is acid, and contains epithelial cells of the pelvis and 

infundibula; also blood-globules and mucus. 
If there be epithelial-cells and pus, it indicates an advanced 
stage. 
In Pyo-nephrosis. 

Urine — is acid, and contains pus in large quantities. 
Pain — exists in the lumbar region. 

Tumor — may be detected at the seat of the pain, which grad- 
ually increases. It may suddenly disappear, when copi- 
ous flow of pus ensues, which affords great relief to the 
patient. 

This tumor may be mistaken for hydro-nephrosis, hydatid 
cyst, and peri-nephritic abscess. 

Pyelitis. 

Is an inflammation of the pelvis and calices of the kidney. 

Produced by stone in the pelvis of the kidney, or inflamma- 
tion extending upward from the bladder, or the use of 
irritant drugs. 

Urine — is acid, and contains blood, pus, and epithelium of the 

pelvis and infundibula. 
No tumor exists. 

Chills and high temperature may be developed. 
Nio pain on motion is present. 
Aspiration — gives negative results. 



PYELITIS. 



389 



feri-nephritic Abscess. 

Is a suppuration of the connective-tissue surrounding the 
kidney. 

A traumatic origin can usually be discovered. 
Urinary symptoms — are negative (unless perforation take 
place). 

Tumor — may occur and point externally. 
Temperature— not so high as in pyelitis. 

Pain — can be detected on motion of the leg and thigh upon 
the trunk. 

Aspiration — by aspirating at the extremity of the last floating 
rib, pus may be drawn off. 

PROGNOSIS. 

1« it be the simple uncomplicated catarrhal form, the prognosis 
is Mvut unfavorable. If both kidneys be affected and there be 
pumicnt discharge, the prognosis is bad. If it be secondary to an 
enlarged prostate or to an extension of a chronic cystitis, urethral 
stricture, or cancer, the prognosis is hopeless. If it occur with 
calculi or hydatids, the prognosis is grave. If there should be 
pyo-nephrosis and the pus escape externally or into the intestines, 
recovery is possible; but if there should be pyo-nephrosis and the 
pelvis bursts into the peritoneal or thoracic cavities, the result 
is usually fatal. 

TREATMENT. 

If of an acute type and the fever be considerable, pain in the 
lumbar region severe, and bloody urine, ivet cups should be freely 
applied to the loins, followed by hot baths and a sufficiently large 
hypodermic of morphine to relieve all pain. The patient should 
be kept in bed and drink freely of alkaline fluids. 

In chronic pyelitis. — Astringents (tannic acid) should be given 
if pus be abundant. . Cod-liver oil and quinine should be admin- 
istered with a nutritious but not stimulating diet, and prolonged 
use of alkaline beverages. Aspiration should be resorted to, if 
the tumor be near the surface, and, should the case require it, a 
free permanent opening should be left. 



390 



DISEASES OF THE URINARY ORGANS. 



3 



HYDRO-NEPHEOSIS. 

SYNONYMS. 
Dropsy of the kidney; renal dilatation. 

DEFINITION. 

Is a non-inflammatory affection, due to a collection of urine in 
the pelvis and infundibula of the kidney from obstruction; com- 
pressing and causing an atrophy of the renal substance and con- 
verting the kidney into a sac or pouch. This dilatation may 
affect the ureter and pelvis, or only the pelvis. 

MORBID ANATOMY. 
The papiUse become flattened, hardened, shrunken, and disap- 
pear. The renal substance gradually diminishes from pressure, 
becomes tough and resistant, and, in extreme cases, the kidney 
becomes a multilocular cyst, sometimes as large as a child's head, 
and the ureters the size of the small intestine, with thickened and 
convoluted walls. The contents of these cysts is variable. 
Urine, which is usually more watery than normal, containing 
more or less urinary salts and also blood, pus, epithelium, and 
albumen, is generally found. 

ETIOLOGY. 

From closure of the ureter by an external tumor, cancer, im- 
paction of calculi or mucus, or by inflammation causing adhesion 
of the walls of the ureters; from stricture of the ureters; from a 
congenital valve at the upper end of the ureters; from an abnor- 
mal course of the renal artery, wnich may be wound round the 
ureter like a cord; from dilatation of the ureter; from an imped- 
ing discharge which may completely close the papillee and pro- 
duce entire suppression of the urinary secretion. 

SYMPTOMS. 

Tumor — detected in the lumbar region, which is of slow develop- 
ment, painless, and fluctuant. In occasional instances, there 



HYDRO-NEPHROSIS. 



391 



is a rapid subsidence of the tumor and a large discharge of 
fluid from the urethra and bladder (diagnostic). 
Rupture of these cysts is uncommon on account of hypertrophy 
of the tunics; the cysts may be of small size, or occasionally 
large enough to contain gallons of fluid. 

DIFFERENTIAL DIAGNOSIS. 
From ovarian cyst; ascites; hydatids; and pyo-nephrosis. 

Between hydro- nephrosis and ovarian cysts: 

In hydro-nephrosis — there is the presence of the colon in front 
of the swelling, and an absence of tympanitic percussion in the 
lumbar region. 

Between hydro-nephrosis and ascites; 

In hydro-nephrosis — there is no dullness in the lumbar regions, 
neither is the line of dullness affected by change in the position 
of the patient. No evidence of portal obstruction can be detected. 

Between hydro-nephrosis and hydatids: 

Unless hydatids be found in the urine it is impossible to make 
a diagnosis. 

Between hydro-nephrosis and pyo-nephrosis: 

In hydro-nephrosis — the urine is non-purulent and there is no 
suppuration. The constitutional symptoms are not so severe as 
in pyo-nephrosis. 

PROGNOSIS. 

When one kidney is affected, the prognosis is favorable, as spon- 
taneous evacuations may occur; but when both kidneys are 
affected, the prognosis is bad, as ursemic symptoms will develop 
and death ensue. 

TREATMENT. 

Evacuate the tumor by careful manipulation, or by aspiration 
at the extremity of the last floating rib. Medical treatment is of 
no avail. 



39a 



DISEASES OF THE URINARY ORGANS. 



EENAL CALCULI. 

These may be formed in the tubes of the pyramids, in the cor- 
tical substance, or in the pelvis. They may occur at any age; 
from the new-born infant to very old age, or even in the foetus. 

MORBID ANATOMY. 
In the aged, the formation of calculi is always associated with 
a gouty diathesis (as deposits of urate of soda in the kidneys, in 
the pyramids, and cortical oubstance). They may also occur in 
connection with diseases of the bone (as carbonate and phosphate 
of lime in the tubes and pyramids). Cysts may be developed from 
permanent impaction, or the calculi may be washed down the 
tubes by the urine, and lodged in the pelvis. They may obstruct 
the ureters and may also tend to excite pyelitis, abscess, paren- 
chymatous nephritis, pyo-nephrosis, or hydro-nephrosis. The 
nuclei of the calculus may be pus, blood, epithelium, grains of 
pigment, etc. 

ETIOLOGY. 

In children, they are usually of the uric acid variety. In adults, 
they are generally composed of lime and triple phosphates (with 
some nuclei, as above mentioned, for a starting-point). 

SYMPTOMS. 

These are aggravated by violent exercise and jolting, as in riding, 
horse-back riding, etc. They may last from a few hours to a 
few days, or the calculi may pass into the bladder and remain 
there, or they may become encysted and cease to irritate. A 
large portion of the kidney may be sometimes destroyed or 
atrophied as the r:sult of a calculus. 

Renal colic — due to the passage of calculus along the ureters; it 
is accompanied by the following syuiptoms: 

Pain — sudden and intense in the region of the kidney of the af- 
fected side, radiating to the bladder, testis, inside of the 



NEW-GROWTHS OF THE KIDNEY. 



393 



thighs, and to the end of the penis. It is so intense that the 
patient often shrieks violently and rolls about. 

Vomiting — violent and frequent. 

Testicle — retracted on the affected side. 

Countenance — pale, and covered with profuse perspiration; great 

anxiety is manifested in the face. 
Pulse — small. 
Extremities — cool. 

Fever— may occur, but is not usually present. 
Urine — may be suppressed or scanty in amount, high-colored, 
bloody, and discharged in drops. It often causes a painful 
burning sensation during micturition, and may contain pus, 
blood, or epithelium. 

DIFFERENTIAL DIAGNOSIS. 
Renal colic may be confounded with neuralgia of the lower in- 
tercostal and abdominal nerves, but the urine containing pus, 
blood, and epithelium decides the question of the presence of 
renal calculi. It may be mistaken for blood-clots, or hydatids in 
the ureters; for spasm of the ureters; and confounded with hepa- 
tic colic (especially if the right kidney be attacked). 

PROGNOSIS. 

Is good, unless there be impaction and obstruction to the escape 
of urine or of the calculus itself. 

TREATMENT. 

Is the same as in pyelitis and pyo-nephritis. The paroxysm 
may be relieved by the free administration of opium, warm baths, 
and hot poultices to the loins and abdomen. If the pain be in- 
tense and the vomiting constant, inhalations of chloroform will 
frequently give speedy and permanent relief. Change of position 
and manipulation along the ureters and drinking something con- 
taining carbonic acid will often aid in dislodging the calculus. 

NEW-GROWTHS OF THE KIDNEY. 

These comprise (1) cancer, which is the only one that is of any | 
clinical importance; (2) tumors in the intertubular tissue; 



394 



DISEASES OF THE URINARY ORGANS. 



syphilitic gummata; (4) fibroma in the pyramids; (5) lipoma, 
wliich are sometimes developed around the capsule of the kidney, 
and in the pelvis of an atropliied kidney, or in the cortical sub- 
stance beneath the capsule, and (6) tubercles (small miliary, gray, 
or cheesy), which are met with only in connection with general 
tuberculosis. 

EENAL CANCEE. 

May be a primary or secondary affection and may occur in both 
kidneys. 

MORBID ANATOJMY. 
These deposits are usually of the medullary variety, developing 
in the form of circumscribed nodules in the cortical substances. 
They may become so large as to fill the whole abdominal cavitj% 
They are often associated with cancer of the testicle. 

ETIOLOGY. 

Depends upon either hereditary taint or some type of local in- 
fection. 

SYMPTOMS. 
Rational. 

Emaciation — gradual. 

Pain — probably none (confined to the lumbar regions, if present). 
Urine — probably no change, but there may be htematuria and 

albumen; when hsematuria is present, it is constant. 
Complexion— a peculiar waxy appearance may often be detected. 
Physical. 

Palpation. — When it attains a large size it can be felt through 
the abdominal walls. Its form and immobility prove it not 
to be an enlargement of the liver or spleen. 

CAUSES OF DEATH. 
Death may result from exhaustion; hemorrhage; acute paren- 
chymatous nephritis; or from invasion from other organs. 

PROGNOSIS. 

Is bad. 



ADDISON'S DISEASE. 



395 



TREATMENT. 

Is palliative, and all that can be done is to relieve the symptoms 
and sustain the patient as much as possible. 

ADDISON'S DISEASE. 
DEFINITION. 

Is a chronic caseous degeneration of the supra-renal car iles, 
attended by a peculiar dark bronzed appearance of the sk . and 
atrophy of the neighboring plexus of nerves. 

MORBID ANATOMY. 
The capsule is sw^ollen, thickened, dark in color, and studded 
with extravasations of blood. It is firm in consistence, and its 
surface is irregular. It presents a grayish-white or whitish homo- 
geneous substance, with caseous collections, and calcareous de- 
posits. These caseous masses are composed of debris and cellular 
elements in a state of decay or degeneration; or crystals of choles- 
terin may often be found. The pigmentary deposit is in the 
lower layer of the rete Malpighi (seen by the microscope). 

ETIOLOGY 

Is unknown. It forms one of the symptoms of general tuber- 
culosis, cancer, and amyloid and fatty degeneration. 

SYMPTOMS. 
Skin — becomes gradually dark. 
Roots of the nails remain white. 
Palms of the hands and soles of the feet are spotted. 
Sclerotic of the eye— is of a pearly hue. 
Black spots appear on the mouth and lips. 
Extreme debility and dementia are often present. 
Pain — in the back and epigastrium usually exists. 
Dyipepsia. 
Vomiting. 

Diarrhoea — obstinate in character. 

Epileptic convulsions — may occur in some cases. 



3^ 



DISEASES OF THE URINARY ORGANS. 



Temperature— usually normal. 

Heart-beat and pulse — at first accelerated, but, toward the end^ 

become weak and feeble. 
Death. 

TREATMENT. 

Good nourishment and care is all that can be suggested, aa it 
usually terminates in death in about four years at the most. 

SURGICAL KID^^EY. 

Is that type of kidney which is liable to be a sequel to opera- 
tions on the genito-urinary tract, especially following the treat- 
ment of deep-seated stricture and operation for stone. 

rt is sometimes called " acute interstitial nephritis," because, in 
extreme cases, suppuration of the intertubular structure takes 
place, forming scattered abscesses throughout the kidney, which 
vary in size from a pin's head upward. 

In the majority of instances, intense renal engorgement is the 
only lesion detected unless evidences of previous diseases exist. 

Its chief symptom is suppression of urine ; and, in fatal cases, 
both kidneys are affected. It is ushered in by a marked chill or 
rigors, within the first two days after the operation. 

TREATMENT. 
Is both preventive and curative. 

Preventive. — Before the operation the patient should be confined 
to his bed for several days; he should have hot hip-baths; and be 
made to drink freely of diluent beverages. Quinine should be 
given in large doses and (Long's treatment) Fleming's tincture of 
aconite, gtt. ij. doses both before and after the operation. 

Curative. — Inf. digitalis and citrate of potash; hot applications ; 
wet cupping; blisters and actual cautery over the lumbar region; 
]iot-air bath; hydragogue cathartics; morphia hypodermically. 



CHOREA. 



399 



CHOREA. 

SYNONYMS. 

St. Vitus' Dance. St. Guy's Dance. It has been termed 
insanity of the muscles." 

DEFINITION. 

Is a disease of a purely motor neurosis, and characterized by 
irregular clonic spasms of groups of muscles under the influence 
of the will, usually occurring on one side of the body, but which 
may become general. 

MORBID ANATOMY. 

The pathology, notwithstanding the numerous autopsies that 
have been made in connection with this disease, is admitted to be 
obscure, for it has never been discovered where the seat of the 
disease occurs in the central nervous organs, nor what are the 
morbid processes in the parts affected. On account of its unilat- 
eral origin and unilateral tendency, the disease is supposed to 
have commenced either in the crus cerebri, or in the correspond- 
ing corpus striatum and optic thalamus or, in the cerebral hemis- 
phere. The majority of authors are totally averse to such opin- 
ions, in consequence of other parts which are supplied by these 
centers being frequently very little, if at all, affected during the 
course of this disease, and, furthermore, its occurring as a sequela 
to other diseases, as will be seen in its etiology. 

Dr. Dickinson, from his results of careful autopsies of several 
fatal cases of this disease, in a valuable paper read before the 
Medico- Chirurgical Society, has come to the conclusion that 
chorea depends " on a widely-spread hyperoemia of the nervous 
centers, not due to any mechanical mischance, but produced by 
causes mainly of two kinds — one being the rheumatic condition, 
the other comprising various forms of irritation, mental and 
reflex, belonging especially to the nervous system, and in conse- 
quence of the vascular changes, sclerosis is induced in the tissues. 



400 



DISEASES OF THE NERVOUS SYSTEM. 



which surround the vessels, thereby explaining the rigidity of 
the limbs, permanent paralysis, and wasting of the muscles, 
which complicate or supervene upon this disease." 

ETIOLOGY. 

It occurs principally in female children at the period of second 
dentition and puberty. It rarely occurs before the sixth or after 
the fifteenth year of life. It may be hereditary. It may even be 
brought on through children mimicking others who have the dis- 
ease (this frequently occurring in large boarding schools). It 
may be due to an irritation of peripheral portions of the nervous 
system. From blows ;. falls ; wounding a nerve ; uterine dis- 
orders ; painful menstruation ; pregnancy (rarely before the end 
of the second month) ; gastric or intestinal affections (by acting 
as the exciting cause of perverted muscular movements) ; strong 
mental emotions (fright, fear); over-fatigue ; over-study ; scarlet 
fever ; rheumatism ; bad hygienic surroundings ; anaemia and 
hydroemia seem to augment the tendency to this disease ; it may 
occur in cardiac complications (rare) or spasmodic action of the 
papillary muscles ; worms ; onanism ; hysteria. 

SYMPTOMS. 

Usually come on insiduously. The child becomes mopish^ 
avoids its companions, takes no interest in games or pleasure, 
cannot commit lessons to memory, or recollect readily. 

Real or apparent mental deficiency. 

Fretfulness or capriciousness. 

Suspicion or timidity. 

Impairment of mental function. 

Restlessness or fidgetiness. 

Clumsy movements. 

Inability to hold things steadily in the hand, and inability to 
write or work. 

Choreic Movements upon one side (usually) either in the face, eye, 
tongue, head and neck, hitching of the shoulders, hand, arm 
(or both hand and arm), sometimes in the leg, may extend to 
the whole side of the body, and may become very character- 
istic, consisting in Sudden impulsive movements following 



CHOREA, 



401 



i^ach other at irregular intervals, involving first one group of 
muscles, then another, then one part of the body, and may 
ultimately involve the whole muscular system. These 
symptoms become greatly aggravated whenever the patient 
endeavors to accomplish any voluntary movement (as in 
drinking a glass of water), or when anything occurs to excite 
him, or when he knows he is being watched. 

Difficulty of speech (due to convulsive action of the lips and 
tongue, or a spasmodic affection of the larynx and the 
respiratory muscles). 

The lower limbs are dragged in walking. 

Mastication and deglutition may be affected. 

Pupils of the eye may be greatly dilated, and the sclerotic coat 
whiter than normal. 

Respiration may be irregular, jerky and noisy in consequence of 
the diaphragm being affected. 

Indigestion (may occur). 

Sphincters of the rectum and bladder maybe affected (in 'severe 
cases). 

Constipation (may occur). 
Impairment of menstrual functions. 

Locomotion or use of the hands may become impossible (in severe 
cases). 

Impairment of muscular strength. 
Paresis (may occur when unilateral). 

Hemiplegia or paraplegia may replace the convulsive move- 
ments. 
Impairment of sensation. 
Eyesight may fail. 

Appetite may be bad, capricious, or even fail. 

Cardiac palpitation (may occur), or even a murmur may be heard, 
which is attributed by Sir William Jenner "to an irregular 
action of the muscular apparatus of the mitral valve, and 
sometimes to an irregular contraction of the heart itself," 
but more probably as the result of anaemia. 

IxxteJilect develops slowly and is enfeebled as long as the disease 
lasts 



402 



DISEASES OF THE NERVOUS SYSTEM. 



Sleep is disturbed, or insomnia (may occur in severe cases after 

assuming the form of nightmare). 
Urine contains an excess of phosphates. 

PROGNOSIS. 

Is rarely fatal, but is not of short duration,, for although being 
of a very acute nature, usually lasts from one to several months 
(due to successive relapses), the patient remaining subject to^ 
nervous disorders, and may in after years be followed by 
epilepsy, insanity, or muscular atrophy. When fatal (in severe 
cases), death is usually due to asthenia, erysipelas, to cardiac 
complications ; or, it may result from extreme agitation ; ner- 
vous exhaustion produced by excessive jactitations, exaggerated 
by sleeplessness, or cerebral rheumatism. 

Complications — Endocarditis and pericarditis, which usually 
precede the disease (being due to rheumatism)— mental derange- 
ments. 

DIFFERENTIAL DIAGNOSIS. 

From spasms of acute cerebral diseases ; from epilepsy ; from, 
tetanus ; from paralysis agitans ; from convulsive tremor ; from 
mercurial tremor ; from facial spasm ; from writers' cramp ; from 
salaam convulsions ; from locomotor ataxia. 

TREATMENT. 

Cold baths have been advocated, as also river and sea-bathing, 
but on account of their great tendency to produce rheumatism 
in children, they have been abandoned by their greatest advo- 
cates. These methods have been replaced by dipping the patient 
in baths (two or three times at first), at a temperature about 75*^ 
F. , gradually lowering the temperature every day. 

Sulphur baths have been also recommended, prepared in the 
following manner, from %tol% ounces of sulphuret of potas- 
sium is dissolved in 12 gallons of water, at a temperature of 
SG'' F. These baths must be repeated daily with the greatest reg- 
ularity, in which the patient is to spend about one hour at a 
time, but where rlieumatism threatens this treatment must not 
be resorted to. 



CHOREA. 



403 



Tonics and the preparations of iron are indicated when the dis- 
ease is due to chlorosis. 

Arsenic (especially Fowler's solution) is largely prescribed, in 
consequence of its possessing the property of causing general 
excitation, and especially, increased vigor of the lower extrem- 
ities. I have seen very excellent results by combining the citrate 
of quinine and iron with this drug. B Lig. pot. arsen : 3 i-ii 
Ferri et quin. cit 3 i-ii. Glycerinoe et aquae aa ^ i.- 3 i t. i. d. after 
meals — gradually increasing the doses of the arsenic every week. 
Should the disease be due to struma, iodine and iodide of potassium 
are indicated. 

Tartar Emetic in large doses, in consequence of its sedative 
action on the nervous system, had its advocates, but was like 
many other remedies abandoned. Dr. Roger, in an article pub- 
lished in the *' Union Medicale," July, 1858, gives the following 
rules for its administration: "On the first day, doses of 4 to 5 
grains in the 24 hours, which is doubled on the second day, and 
trebled on the third day, and then a period of rest for 3 to 5 days. 
If the disease persist, or the convulsiye movements merely di- 
minish in violence, the drug is again administered for another 
three days, beginning with the same dose as on the first day, plus 
an additional grain, then an additional rest. If, after this period, 
the disease recur, the same plan is adopted. So that, if the first 
dose, given on the first day of the first series, be 4 grains, that on 
the first day of the second series 5 grains, and on the first day of 
the third series 6 grains, and on the third day of the third series 
18 grains." Antispasmodics and narcotics such as assafaetida, 
camphor, musk, valerian, etc., have been recommended, put 
aside, and tried again. 

Cannabis Indica has been greatly praised by Dr. Corrigan, of 
London, who commences the treatment by giving 5 minims of 
the tincture three times a day for a week or ten days, then 
gradually increasing the dose to 25 min. three times a day. 
This drug possessing, as it does, an alterative action on the ner- 
vous system, should be used in obstinate cases, especially where 
narcotics are indicated, in order to prevent dangerous complica- 
tions. 

Opium finds a" strong advocate in Trousseau, where the disease 



404 



DISEASES OF THE NERVOUS SYSTEM. 



is complicated by insomnia, which gradually exhausts the 
patient's strength, the sulphate of morphia being preferred, giving 
it in grain doses every four hours. He increased the dose until 
30 grains had been administered in the twenty-four hours, when 
he obtained complete recovery. In very severe cases, when the 
movements become beyond control, chloroform should be admin- 
istered. 

Sulphate of Zinc, from 3 to 3 grains three times a day, dis- 
solved in a sufficient quantity of water to prevent gastric irrita- 
tion, was at one time used by Dr. Hammond, of this city, but he 
now prefers the bromide, beginning with ten drops, three times a 
day, increasing the dose till the symptoms begin to disappear, 
and then decreasing the dose accordingly. 

Gymnastic Exercises have their advocates among many prac- 
titioners, which, when properly carried out have many advan_ 
tages. Whenever the vertebras are sensitive to pressure, leeches 
and cupping have been applied to the side of the spine, followed 
by counter-irritants. 

Hygienic Measures, as they occupy a prominent part, should 
not be forgotten in this disease. The patient should sleep in a 
well- ventilated room ; nutritious and tonic food should be taken 
at regular intervals ; cod liver oil, if there be great debihty ; open 
air exercise, without producing fatigue, in order to facilitate the 
organic movements of repair, thus preventing recurrence of the 
disease ; the bowels should be properly regulated ; cold bathing 
and swimming may be indulged in in moderation. When the 
disease assumes the severe type it is advisable to separate the 
patient from others, on account of the annoyance, and because 
the affection is apt to extend from one to the .other from sympa- 
thetic irritation. 



PEESCEIPTIONS. 



PEESCRIPTIONS. 



ALKALINE MIXTURE For Nursing 
Children. 

9 Pot- carb gr, ij. 

01. cajuput Til i. 

Aq. anethi 3 ij. 

M. Sig. three or four times a day. 

ASCARIDES. 
^ Quassise 3 ij. 

Ac. salicyl gr. x. 

Aquae O.i. 

M. Sig. to be used as an enema. 

ASTHMA. 
1^6 Fl. ext. ergotge, 

Tr. hyos aa^i. 

HofE. anodyne 3ij. 

M. Sig. 3 i. every half -hour till re- 
lieved, then every 2 hours for the next 
24 hours ; then give 

3^ Mist, glycyrrh § ii j. 

Tr. opii camph 5 i. 

Ammon. mur gr. Ix. 

M. Sig. 3 i. t. i. d. 
If it become severe, paint the chest 
with 

1^ Canth. coUod. sol. over a space 3 
inches by 8 inches and give 



Hyd. chlor. mifc gr. x. 

Pulv. Jalapse gr. xv. 

Or, 

^ Pot. iodidi, 

Tr. bella aa 3i. 

Liq. pot. arsen. tti xl. 

Spts. ether, co I iss. 

Elixir simpUcis 1 ij. 

Aq. ciimamon 5 vi. 



M. Sig. 3 iv. t. L d, after meals. 



ASTHMA (Hay), 

^ Pot. iodidi 5 i. 

Liq. pot. arsen 3i, 

Aquas 51v. 

M. Sig. 3 i. every 4 hours. 
Or, 

^ Liq. pot. arsen 3 iij. 

Tr. bella 3 ix. 



M. Sig. gtt. xij. after meals, and in- 
crease in 3 days to xvi., and after 10 
days to gtt. xx. 

ASTHMA (In Pregnancy). 



]^ Pot. brom 3 iij. 

Chioral hydrat 3 ss. 

Aquae ^i. 

M. Sig. 3 j. to be used as required. 
Or, 

^ Pot iodidi 3 i. 

lodini gr. I 

Tr. gent, co li. 

Aquae 5 ij. 

M. Sig. 3 i. t. i. d. 



ASTHMA (Spasmodic). 

IJ Pot. iodidi gr. xv.-xxx. 

Every 2 or 3 hours. 

ASTHMA (In a Child). 
First, for sneezing, keep the bowels 
open with a Gregory's powder, and 
give 

Pulv. Dov., 

Quin. sulph aagr, viij. 

Also, 

Spts. nit. dulc, 
Tr. Scilla;, 

Tr. opii camph aa ^i- 

Sig. 3 i. every hour till relieved. 



408 



PRESCRIPnONS. 



ASTHMA (With Emphysema and 
Chronic Bronchitis), 

B S5T. prun. virg § iv. 

Hoflf . anodyne | ss. 

Pot. iodidi 3 ij. 

Tr. bella 3ij.-iv. 

M. Sig. 3i. t. i. d. and send the 
patient to a warm climate. 

AN.EMIA (In Childekn). 

^ Ferri cit 3 ij. 

Aq. aurant | vss. 

Syr. simplic f ss. 

M. Sig. from a teaspoonful to a 
tablespoonful before or after each 
meal. 

ANEMIA. 
3 Tr. ferri perchlor., 

Acid. acet. dil aa lU xx. 

Syrupi 3 ij. 

Liq. ammon. acet 3 \i. 

M. Sig. 3 ij.-iv. every three hom"s. 

ACNE, 

^ Tr. sap. vir | iij. 

Ac, carbol 3 ss. 

Sp. vini rect — ad liv. 

M. Sig. to be used at night. In the 
morning the parts should be washed 
with warm water and then rubbed 
down with 

Fngt. hydrarg, ammon., 

Zinci oxidi aa | ss. 

ANEURISM. 

^ Pot. iodidi gr. xv.- 3 ss. 

Sig. take this amount t. i. d. 

APERIENT. 

B Fl. ext. rhei tti, xl. 

Fl. ext. ipecac ^ iij. 

Sodii bicarb 3ij. 

Aq. menth. pip ad | ij. 



AMENORRHCEA, 

5 Ferri. arsen gr. 

Ergotinae (aq. ext.) 33s, 

M. et ft. pU. XXX. 
Sig. One night and morning. 
Or (Tonic). 

Sulph. strj'ch gr. L 

Ferri. pyrophos., 

* Quin. sulph aa3L^ 

Ac. phos. dil., 

Syr zingiber aS^ij. 

M. Sig. 3 i. t. i. d. 

ANGINA PECTORIS. 

Ammon. valer .gr. v.-r. 

Chlor. ammon gr. xxx. 

Sig. take immediately. 
Or, 

5 Tr. rhei et sennae lias. 

Syr. zingib 3 iij. 

Tr. opii 5 i. 

M. Sig. 3i- in hot water inimedi' 
ately. 

ANIJS (Itching ov). 
5 Pot. brom., 

Chlor. hydrat iia gr. x.-xv. 

Aquae 5«. 

M. Sig. To be taken at bed-time. 
Also, 

^ Sodii bibor 3 ij. 

Morph. mur gr. xvi. 

Ac. hydrocyan. dil — Jss. 

Glycerinae lij. 

Aquae ad 5viij. 

M. Sig, to be applied to the affected 
part. 
Or, 

5 Cliloroformi 3 ij. 

Glycerinae Jss. 

Cerat. simp fiss. 

M. et ft. ungt. Apply locally. 

(* Tr. hydrast. may be substituted.^ 



PRESCRIPTIONS. 



409 



ARTHRITIS (Chronic). 



^ Lithii brom 3 iij- 

Syr. zingiber.^ 3 ss. 

Aquae 5 iss. 

M. Sig. 3 i. t. i. d. 

Or, 

1^ Lithii carbonat 3 j. 

Ac. citrici 3 ij. 

Aquae 5iJ. 



M. Sig. 3 i. t. i. d. 



ARTHRITIS. 



01. sassafras 3 ij. 

Aq. ammon 3 iy. 

Lin. sap. camph 5iij. 

M. ft. liniment (for ext. application). 

APHTHA OF PHTHISIS. 

^ Quin. sulph gr. i. 

Olei piperis nig .gtt. i. 

Aquae 5 i. 

Sig. apply with a brush or rinse otit 
the mouth. 



% 



PRESCRIPTIONS. 



410 

BLADDER (Inflam. of). 



^Tr. bella Zl 

Fl. ext. buchu 5i. 

Liq. pot. arsen 3 ss. 

Syr. simp I iss. 

Tr. opii camph 3 vi. 

Aquae ad 5 vi. 



M. Sig. 3 i. every 3 hours. (Tr. opii 
carnph. should not be included when 
blood exists in the urine.) 
'Or, 

^ Pot. brom 3 iij. 

Chloral hydrat 3 iss. 

Syr. rub. idaei, 

Aquae . aa ^i. j 

M. Sig. 3 i. every half-hour till re- 
lieved (and apply hot fomentations). 

BLADDER (Irritation of). 

^ Palv. opii gr. ij. 

01. theobro q. s. 

M. ft. suppos. 1. 
Or, 

Acid, benzoic 3 ij. 

' Aq. cinnam | vi. 

M. Sig. a tablespoonful t. i. d. 

BREAST LOTION. 
^ Ext. bella 3i.-ij. 

Pulv. camph 3 i. 

Glycerinae Iij. 

Chloroformi 3 ss. 

01. menth. pip 5 i. 

M. Sig. apply locally. 

BILIARY CALCULI. 

^ Phos. sodae 3 i. 

Sig. take this t. i. d. 
Or, 

Bismuthi, 

Inf. calumb &a 3 ij. 

Ilydrat chloral 5 ss. 

Syr. rub. idaei, 

Aquae aajij. 

M. Sig. 3 i. t. i. d. 



BRONCHITIS. 

R Pot. nit 3ij. 

Pulv. sacch. albi 3 ij. 

M. et ft. chart, xij. 

Sig. one every two or three hours. 

BRONCHITIS (Acute). 

Vini ipecac 3 ij. 

Liq. pot. cit | iv. 

Tr. opii camph., 

Syr. acaciae .\ . .aa | i. 

M. Sig. 3 ij. t. i. d. 
Or, 

3J Ant. et pot. tart., 

Morph. acet , . . aa gr. i. 

Aquae destil ^iv. 

M. Sig. 3 i. every hour. 

BRONCHITIS (After Loosening of 
Cough). 

^ Syr. scillae 5 iij. 

Tr. opii camph.. li. 

M. Sig. 3 i. t. i. d. or 3 ij. at night. 

BRONCHITIS (Chronic). 

^ Ammon. chlor 3 i j. 

Mist, glycyrrh. co. 5 iij* 

M. Sig. dessertspoonful t. 1. d. 
Or, 

]^ Ext. eucalypt | i. 

Ammon.»mur., 

Ext. glycyrrh aa 3 ij. 

Syr. tolu I iij. 

M. Sig. 3 i. every two hours. 
Or, 

^ Ammon. chlor 3 iij. 

Muc. acaciae fl. 5iv. 

M. Sig. a tablespoonful four times a 
a day. 

BRONCHITIS (With Dry Cough). 

^ Antimon. tart gr. i. 

Syr. scillae 5 iv. 

M. Sig. a tablespoonful every 3 
hours. 



PRESCRIPTIONS. 



BRONCHITIS (Chronic) (With Asth- 
ma AND Emphysema). 

^ Syr, prun. virg 5 iv. 

Spt. oether. comp. (Hoff.)- § ss. 

Pot. iodidi 3 ij. 

Tr. bella 3 ij.-iv. 

M. Sig. 3 i. t. i. d. and send the pa- 
tient to a warm climate. 

BRONCHITIS (Acute in Children). 

15 Tr. ver. vir • nij. 

Syr. scillae comp 3ii. 

Syr. balsam, tolu 3 xiv. 

M. Sig. 3 i. every 2 or 3 hours to a 
child 5 years old, in first stage of the 
disease. 



411 

BRONCHITIS (In Infants). 
^ Syr. senegas 3 i. 

Syr. tolu lij. 

Ammon. mur gr. x. 

M. Sig. 3 i. (small) every 3 hours. 

BRONCHITIS (2d Stage). 

* ^ Sulph. morph gr. i- 

Syr. bals. tolu., 

Syr. prun. virg aa ^i. 

M. Sig. 3 i. t. i. d., and if there be 
night-sweats add morphine gr. 1-60. 
Or, 

^ Sulph. morph gr. i. 

Vin. antimon 3 ij- 

Syr. tolu I iss., 

Aquae 5 iij. 

M. Sig. 3 i. t. i. d. 



412 



PRESCRIPTIONS. 



CALCULI (Bn.TARY). 
5 Bismuthi, 

Inf. calumb aa 3 ij. 

Hydrat chloral | ss. 

Syr, rub. idsei, 

Aquse aa^ij. 

CARDIAC HYPERTROPHY (Witij- 
ouT Valvular Lesion). 

IJ Fl. ext. ergotae ^iliss. 

Tr. digit |ss. 

M. Sig. 3 i. t. i. d. 

CATAaiENIA (Stopped). 

B Pot. brom 3 iv. 

Aquae lij. 

M. Sig. 3i. t. i. d. 

CHANCRE. 

R Hyd. chlor. mit 3 i. 

Liq. calcis liv. 

M. et ft. lotio. Sig. apply on lint. 
Or, 

R Hyd. chlor. corr... . .gr. xvl. 

Liq. calcis ! viij- 

M. et ft. lotio. Sig. apply on lint. 

CLAP. 

^ Tinct. hydras. 3 ij. 

Aquae 5 viij- 

M. ft. lotio, inject 3 or 4 times daily. 
Or, 

^ Fl. ext. hydi-as., 

Glyceringe aa 3 ij- 

M. et ft. lotio for injection, t. i. d. 
And, 

5 Tinct. gelsemii 3 i. 

Aquae liij. 

M. Sig. 3 i. every 4 hours. 
Or, 

5 01. santalis flavae 3 ij. 

01. cinnamomi niij' 

M. Sig. Take gtt. x-xv. on a piece 
of sugar t. i. d. (and as much milk as 
possible, but no spirits). 



CRABS. 

B Tr. delphini | i. 

Sig. Put on sponge and sponge the 
parts. 

CATHARTIC. 

R Strych. sulph gr. i. 

Res. podoph gr. x. 

Ext. col. CO gr. xl. 

Pulv. capsici gr. xx. 

M. et ft. pil. xl. sig. One or two when 
required. 

CEREBRAL CONGESTION. 

B Sodii brom 31. 

Fl. ext. ergot. (Squibb's) . . 3 iv, 
M. Sig. Tablespoonful t. i. d. 
Or, 

R Sodii brom 31. 

Pep. sacch., 

Lig. carb. pulv aa 3 iij. 

Fl. ext. ergot., 

Aquee aa^ij. 

M. Sig. 3 i. t. i. d. for one month. 
Then give as a tonic : 

5 Quin. sulph gr. iv. 

Ac. hydrobrom 3 iv. 

M. Sig. 3 i. t. i. d. after meals. 

CHILBLAINS. 

3 Plumb, acet ^ss. 

Aquae O.i. 

M. Sig. Apply as a lotion to the af- 
fected parts. 
Or, 

Bi Acid, carbol 31. 

Tr. iodini 3 ij. 

Acid, tannici 3ij. 

Cerat. simp liv. 

M. Sig. Ungt. 

COLIC. 

B Sodii bicai'b., 

Spt. oether comp. (Hoflf.), 
Morph. sol., 

Syr, zingiber aaSSS. 

Aq.camph.,ad 5ij. 

M. Sig. 3 i. repeat till relieved. 



PRESCKIPTIONS. 



413 



COLLYRIA. 

5i Atrop. siilph gr. iv. 

Aq. dest ...fl. li. 

Or. 

1^ Duboisias sulph gr. M' 

Aq. dest fl. iL 

Or, 

^ Eserinae gr. ij. 

Aq. dest fl.fi. 

Or, 

U Zinci sulph gr. iv. 

Aq. dest fl. 

Or, 

5s Aluminis gr. ij. 

Aq. dest fl. 

Or, 

^ Acidi galliei 3 ij. 

Glycerinas fL^i, 

Xy CONSTIPATION. 
5s Tr. nuc. vom., 
Tr. bella., 

Tr. physost aa 3 ij. 

M. Sig. gtt. XXX. in water morning 
and evening. 
Or, 

^ Ext. physostig.. 
Ext. bella.. 

Ext. nuc. vom aa gr. v. 

Ft. pil. X. Sig. one pill at bed-time. 
Or, 

^ Aloes soc. 

Sap. Castil ..aa 3i. 

Ext. hyos gr. X. 

Pulv. ipec gr. V. 

M. et ft. pil, XX. Sig. take one night 
and morning. 
Or, 

1} Ext. bella gr. v. 

Ext. nuc. vom gr. x. 

Ext. col. CO 3i. 

Sodii carb. exsiccat gr. xl. 

M. et ft. pil. xl. Sig. take 2 at bed- 
time. 



CONSTIPATION. 
Or (In Children). 

^ Podoph gr. i. 

Sacch. lactis 3 i, 

M. et ft. chart, xx. Sig. take one 
every morning or night. 
Or, 

B Pulv. rhei gr. iij. 

Sodii bicarb gr. x. 

Pulv. zingib gr. ij. 

M. et ft, chart, i. 
Or, 

B Ext. colyc. CO. . gr. ij. 

Ext. bella gr. ^. 

Ext. gent gr, i. 

01. carui gtt.^s. 

M. et ft. pil. i. 
Or, 

B Resin, podoph gr. 1-6. 

Pulv. rhei gr. ij. 

Ext. bella gr. ^ 

01. carui gtt. SS. 

M. et ft. pil. i. 
Or, 

^ Rhei rad. , 

Sapon. Castil aa3ss. 

01. anis gtt. iv. 

M. ft. pil. XX. Take one or two as 
required. 

Or, when obstinate, 

B Rhei 3ij. 

Aloes 3 i. 

Ext. nuc. vom gr, iv, 

M. et ft. pil. xl. One or two as re- 
quired. 

Or (Chronic in Women). 

B Ext. bella. gr. v. 

Ext. nuc. vom gr. x. 

Ext. colocynth. co 3 i. 

M. ft. pil. xx. Take one at night. 
Should griping occur, add sodii bicarb, 
and make pil. xl. Take 2 at bed-time^. 



414 



PRESCRIPTIONS. 



CONSTIPATION. 
Or (During Pregnancy). 

9 Ext. aloes gr. iv. 

Nuc. vom gr. i. 

Ext. hyos ...7 gr. iv. 

(Or, ext. bella gr. i.) 

M. et ft. pil. iv. Sig. take one every 
morning. 

Or (In Infants). 

Resin podoph gr. i. 

Syr. rhei 3 i. 

01. foenic gtt. i. 

M. Sig. gtt. X.- 3 i. -v 
Or (In Women). 

Ext. col. CO gr. iij. 

Ext. bella gr. X. 

Saponis gr. i. 

M. et ft. pil. 1. Take one every night. 

COUGH. 

3 Morph. sulph gr. ij. 

Ac hydrocyan. dil 3 ss. 

Syr. scillae, 

Syr. tolu aa 5 ij. 

M. Sig. 3 i. every 2 hours till relieved. 
Or, 

^ Ammon. chlor 3 ij. 

Morph. sulph gr. ij. 

Tr. aeon, rad ttl xvi. 

Fl. ext. bella til v. 

Fl. ext. glycyrrh., 

Syr. simp aa|i. 

Aquae ad 5 iv. 

M. Sig. 3 i. every 2 hours. 
Or (Reflex of Pregnancy). 

^ Pot. brom gr. xx. 

Chloral hydrat gr. v. 

M. Sig. this amount to be taken at 
bed-time for 2 or 3 weeks. 
Or (When Violent and Trouble- 
some). 

^ Ac. hydrocy. dil gtt. xvi. 

Syr. prunis virg fl. 5 i. 

M. Sig. 3 i. every 2 or 3 hours. 



COUGH. 
Or (Troublesome). 

5 Syr. scillee ^iss. 

Spt. oeth rconip. (HolT).... ^i. 

Morph. sulph gr. i. 

Aq. camph., 

Muc. acaciae. . . aa ? i. 

M. Sig. 3 i.-iv. t. i. d. 

COUGH MIXTURE (Adult). 
^ Syr. senega, 

Syr. prun. virg. , 

Syr. tolu aa^i. 

Tr. opii camph., 

Sp. nit. dulc aa^ss. 

Ammon. mur 3 ss. 

M. Sig. 3 i. t. i. d. 

COUGH SYRUP. 

B Morph. acet gr. X. 

Tr. hyos 3iss. 

Syr. tolut 3iiss. 

Aq |ss. 

M. Sig. 3 ij. every three hours. 

CHOREA. 

]^ Liq. pot. arsen | i. 

Sig. gtt. ij. t. i. d. and increase gtt. 
i. every week. 
Or, 

^ Elixir phos 5ij. 

Sig. 3 i. t. i. d. 
Or, 

R Zinci valer 3ij. 

Cinchonias sulph 3 i. 

M. ft. pil. XX. Sig. one pill t. i. d. 
Or, 

Zinci brom 3 i. 

Syr. simp 5 i. 

M. Sig. gtt. X. t. i. d. and increased 
so soon as the stomach can bear it. 
Or, 

5, Strych. sulph gr ij. 

Aquae ? i. 

Sig. gtt. V. t. i. d. to a child fi-om 10 
to 15 years old. 



1 iLElSCRIPTIONS. 



415 



CHOLERA INFANTUM. 
^ Tr. opii comp. (Squibb's). . . 5 i. 
Sig. gtt. X. every hour in water till 
relieved. 

Or, 

B Cup, sulph gr. i. 

Tr. opiideodor gtt. viij. 

Aq. destil 5 iv. 

M. Sig. 3 i. every 2, 3, or 4 hours till 
relieved. 

Or, 

B Tr. zingib. , 

Tr. menth. pip aa 3 i. 

Tr. opii camph 3ij. 

Aq. menth. pip ad 

M. Sig. 3 i. every hour. 
Or, 

BMist.creta ^ij. 

Tr. catechu, 
Lactopeptin, 

Bismuth . subnit . . . . aa 3 i. 

Tr. opii gtt. xij. 

M. Sig. 3 i. every hour in w^ater till 
relieved. 

Or (With Vomiting, etc.). 

^ Pepsin (Boudault's) — 3 ss. 

Bismuth, subnit 3 i. 

Ingluvin 3 ss. 

Tr. opii camph gtt. xvi. 

Aq. anisse | ij. 

M. Sig, 3 i. every three hours. 
Or (In a Child 6 Months Old). 
B Sodii bicarb gr. vj. 

Pepsin gr. xx. 

Ingluvin gr. xv. 

Pul/. opii gr. 88. 

r.I. et ft. chart, vij. 



C^IOLERA MORBUS. 
R Plumbi acet., 

Pulv. camph aa gr. vi. 

Pulv. opii gr. i. 

Ext. gent q.s. 

M. ft. pulv. vi. Sig. One every three 
hours till relieved, and if vomiting 
very bad give, 

R Plumb, acet gr. viij. 

Morjihiae acet gr. i. 

Aq. camph lij. 

M. Sig. 3 i. every hour. 

CHORDEE. 
B Camphorse, 

Lactucarii aaji. 

M, et ft. pil. xxx. Sig. take 1, 2, or 
more as necessary. 
Or, 

R Vin. colchici ^, xxx. 

Sig. to be taken every night. 

CHLOROSIS 
R Tr, ferriperchlor., 

Ac. acet. dil ' . . .aa iH, xx. 

Syrupi 3 ij. 

Liq. ammon. acet 3 vij. 

M. Sig. 2 to 4 teaspoonfuls every 3 
hours. 

CROUP. 

R Hyd. sulph. flav gr. xij. 

Pulv. sacch. albi gr. xxx. 

M. et ft., chart, vi. Sig. give one 
every 1^ hour till vomiting be produced. 

CEREBRAL CONGESTION. 
(For a Child G Years of Age). 

B Potass, brom 3 iv. 

Potass, iodidi 3 ss. 

Fl. ext. ergotse (Squibbs) 3 ij. 

Syr. rub. idoei, 

Aquae Sa? j. 

M. Sig. 3 i. every three hours. 



416 



PRESCRIPTIONS. 



DEAFNESS (With Discharge). 

^ Hydrarg. perchlor gr. v. 

Liq. opii 3 ss. 

Glycerinae 5i. 

Aquae ad 

M. Sig. Fill the ear morning and 
evening with equal parts of hot water 
and the above preparation. 

DEBILITY (With Nervousness. 

Pot. brom li. 

Ferri sulph. exsicc 3 ss. 

Calumbae, 

Zingiberis aa 3 iv. 

M. et ft. chart, xxiv. One at bed 
time. 

DELIRIUM TREMENS. 

^ Tr, capsici 3 vi. 

Tr. nuc. vom 313. 

M. Sig. gtt. XX. in water every 4 
hours. 

Or, 

^ Morph. sulph. sol,, 

Fl. ext. valerian aafl. li. 

M. Sig. 3 i.-ij. as required. 
Or, 

^ Pot. brom 3 iv. 

Chloral hydrat 3 iij. 

Aq § ij. 

M. Sig. 3 i. every 3^ hour till re- 
lieved. 
Or, 

1^ Chloral hydrat gr. xxx. 

Every % hour, 

DEPRESSED SPIRITS. 

]^ Ac. nit. mur | ss. 

Sig. gtt. X. t. i. d. in water. 

DYSMENORRHCEA. 

1^ Pulv. Opii 

01 theobro 

M. ft. suppoe. 1, 



gr. ij. 
.q.s. 



DYSMENORRHCEA. 
Or (From Anemia). 

^ Sulph. strych gr. i, 

Ferri pyrophos., 

*Quin, sulph aa3i. 

Ac. phos. dil., 

Syr. zingiber aa 5 i j . 

M. Sig. 3i. t. i. d. 

DYSENTERY (With Tenesmus). 
^ lodoformi, 

Pulv, opii aagr. viij. 

M. ft. pil. viij. Sig. One every 2 
hours unless allayed. 
Or (Acute). 

Cup. sulph gr. ss. 

Mag. sulph li. 

Ac. sulph. dil 3 i. 

Aq. , ? iv. 

M, Sig. a tablespoonful every four 
hours. 

Or (Asthenic). 

]^ Aq. camph 2 iv. 

Acidi nitr tti xxx. 

Tr. opii TTi xxx, 

M. Sig. A tablespoonful every 2 or 
3 hours. 

Or (Chronic). 

Liq. pot. arsen .gtt. ij. 

Tr. opii gr. V. 

M. Sig. Take this before each meal. 
Or (Chronic). 
R Cup. sulph., 

Morph. sulph aagr. i, 

Quinise eulph gr, xxiv. 

M. et ft. pil. xij. Sig. One t. i. d. 
Or (Chronic). 
^ Fl ext. ergot, (Squibb's). 3 iiiss. 

Tr, opii deodor ^ ss. 

M. Sig. 3 i. t, i. d. 

* Tr. hydrastis may be substituted. 



PRESCRIPTIONS 



417 



DYSENTERY. 
Or (In a Child 5 Years op Age). 

lodoformi gr. xv. 

Mucil. aeac | i. 

Aeiditannici gr. xl. 

M. Sig. put 3 i. in some thin boiled 
starch and inject per rectum. 

Or (In a Child 5 Years of Age). 

Plumb, aeet gr. xx. 

I*alv. opii... gr. i. 

Ergotin gr. iv. 

Glycyrrhiz q.s. 

M. et ft. chart, x. Sig. One every 2 
hours. 

DYSPEPSIA. 

^ Sodii bicarb gr. xx. 

Acid carbol gtt. ij. 

Acac, 

Sacchari albi aa q. s. 

Spts. lavand. co 3 ij. 

Aq 3 vi. 

M. Sig. 3 i. two hours after each 
meal. 
Or, 

^ Pulv. pepsin., 

Bismuth, subcarb . . ..aa gr. xx. 
M. et ft. chart, x. Sig. take one t. i. d . 
Or, 

B Tr. gent, co., 

Tr. rhei aa^ij. 

M. Sig. 3 i. before each meal. 
Or (And Vomiting), 

B Bismuth, subcarb gr. x. 

Sodii bicarb gr. iij. 

M. et ft. chart, i. 

Or (Chronic). 

^ Arg. oxidi, 

Ext. hyos aagr. V. 

M. et ft. pil. X. One t. i, d. before 
meals. 



DYSPEPSIA. 
Or (Sour Risings after Meals). 

^ Inf. calumb liv. 

Liq. potass 3 ss. 

M. Sig. 3ij. t. i. d. half an hour 
before each meal. 

Or (When Hands and Feet Cold). 

^ Asafoetidse gr. iij.-ix. 

Sodii bicarb gr. ij. 

Paradise semen gr. i. 

M. put the above pill in capsule (one 
should be taken t. i. d.). 

DYSPEPTIC TONIC (After Fevers, 



etc.). 

^ Ammon. carb 3iv. 

Ferri ammon. cit 3i. 

Tr. nuc. vom 3 ij. 

Tr. quassiaB, 

Tr. gent, co aa§iv. 

Elixir simp 5 iij. 

Aq. camph adO.i. 

M. Sig. 3 ij.-iv. t. i. d. before or 
after meals. 

DIARRHCEA. 

Morph. sulph gr. ss. 

01. theobrom q. s. 

Ft. suppos. No. 1. 
Or, 

^ lodoformi gr. v. 

01. theobrom q. s. 

Ft. suppos. No. 1. 
Or, 

B Morph. sulph gr. ss. 

Ext. bella gr. Iss. 

01. theobrom q. s. 

Ft. suppos. 1. 
Or, 

^ Morph. sulph gr. ss. 

Ext. bella gr. iss. 

Ac. tannici gr. v. 

01. theobrom q. s. 

Ft. suppos. 1. 



418 



PRESCRIPTIONS. 



DIARRHOEA. 

Or. 

B Ac. tannici gr. v. 

01. theobrom q. s. 

Ft. suppos. No. 1. 
Or, 

B Aq. camph liv. 

Acidinit lUxxx. 

Tr. opii TTl XX. 

M. Sig. A tablespoonful every 2 or 
3 hours. 
Or, 

B Pulv. opii gr. j. 

Plumb, acet gr. ij. 

M. et ft. pil. i. 
Or, 

B Pulv. opii gr. j- 

Acid, tann gr. iij. 

M. et ft. pil. i. 
Or. 

B Spts. lavan. co |i. 

Spts. camphor 3 i. 

Tr. opii 3 ss. 

Sacch. albi, 

Muc. acac aa3iss, 

Aq. cinnam ad 1 vi. 

M. Sig. A tablespoonful every 3 

hours. 

Or, 

B Tr. opii gtt. XX. 

Bismuth, subnit 3ij. 

Syr. simp 5 i. 

Mist, cretae ^iij. 

M. Sig. 3 i. every 3 hours. 
Or, 

B Mist, cretae 3 ij. 

Lactopeptin 3 i. 

Tr. catechu 5i. 

M. Sig. 3 i. eveiy 2 hours. 
Or. 

B 01. ricini 3 i. 

Tr. zingib gtt. xx. 

Tr. opii gtt. x.-xx. 

Vin. gallici 5 i. 

M Rig. Take at once. 



DIARRHCEA. 

Or, 

B Bismuth, subnit 3 ij. 

Morph. sulph gr. i. 

M. et ft. pulv. vi. Sig. 3 i. t. i. d. in 
milk. 
Or, 

B Ac. sulph. arom H^d. 

Ext. haematoxyli 3 i, 

Tr. opii camph 3 iv. 

Syr. zingiberis. 3 iv. 

M. Sig. 2 teaspoonfulseveryShours. 
Or, 

B Mist, ci-etae 3 v. 

Tr. catechu, 

Tr. opii camph aa 3 iss. 

M. Sig. Dose one teaspoonful every 
3 hours. 
Or, 

B Tr. calumb 3 xv. 

Tr. opiideodor 3i. 

M. Sig. 3 i. in wine-glass of water 
before meals. 
Or (Chronic). 

B Liq. pot. arsen gtt. ij. 

Tr. opii gtt, V. 

M. Sig. Take this before each meal. 
Or (Chronic). 
B Cup. sulph., 

Morph. sulph aagr. i. 

Quinige sulph gr. xxir. 

M. et ft. pil. xij. Sig. one t. i. d. 
Or (Chronic). 
B Fl. ext. ergot. (Squibb's). 3 iiiss. 

Tr. opiideodor 5ss. 

M. Sig. 3 i. t. i d. 
Or (In Child C to 9 Months, with 
Green Stools). 

B Pepsin 3 ss. 

Bismuth, subnit 3 i- 

Tr. opii gtt. XX 

Aq. menth. pip., 

Aqupe lauro cerasi aa 5 i. 

'}[. Sig. 3 i. ever3'3 hours. 



PHESCRIPTIONS. 



419 



DIAERHCEA. 
Or (In Typhoid Fever), 
3 Bismuth. subcarb..gr. xxx.-lx. 
Sig. Take this t. i. d. in milk. 

DIARRHCEA OF PHTHISIS. 

^ Resin, terebin gr. iij. 

Argent, nitrat., 

I'ulv. opii, aagr. ^. 

Sig. One pill when needed. 
DIARRHCEA (Summer). 

^ Mag. sulph 5i. 

Ac. sulph. dil 3 ij. 

Morph. sulph gr. i. 

Aq liv. 

M. Sig. 3 ij. every 3 or 4 hours. 
Or (Summer, in Adults). 

^ Mag. sulph 3 vi. 

Tr. rhei, 

Tr. zingiberis aa I iss. 

Aq. menth. pip ad l-vi. 

M. Sig. 3 iv. t. i. d. 
Or (Summer, for Children 1 Year 
AND Under). 

^ Mag. sulph — 3i. 

Tr. rhei 3 ij. 

Syr. zingiber 3 ivi 

Aq. menth. pip .ad | iss. 

M Sig. 3 i. every 3 hours. 



DIPHTHERIA. 

?i Tr. ferri mur 3 iss. 

Sat. sol. chlor. pot 5 ij. 

M. Sig. 3 i. every 2 hours. 
Or, 

R Tr. ferri persulph 5 ss. 



M. Sig. Put 3 i. in a tumblerful of 
water and gargle the throat. 
Or, 

5 Hydrarg. prot. iodidi, 

Pot. bichrom aa 3 iv. 

M. Sig. Put sufficient in a tumbler 
of water to make it a deep yellow and 
take a teaspoonf ul every hour. 



Or, 

B Pot. chlor 5 s8. 

Aq , 5 vi. 

M. Sig. Tablespoonful t. i. d. 

DROPSY. 

B Vin. colch. sem . 5 ss. 

Sol. ammon. acet |iiss. 

Inf. petroselin ^y. 



M. Sig. A tablespoonful every four 
hours. 



420 



PRESCRIPTIONS. 



EAU-ACHE. 



^ Chloroform i 3 i. 

Vini opii, 

Glycerin aa3 ij. 

01. amygdal 3"]. 



M. Slg. gtt. i. or ij. to be dropped 
in the ear night and morning. 

ECZEMA. 

TJng. zinc, ox., 

XJng. hydrarg. nit., 

Ung. plumb, subacet. . . aa 5 ss. 
- M. et ft. ungt. Apply to parts af- 
fected. 
Or, 



5 Acid. nit. dil 3ss. 

Plumb, acet gr. v. 

Aq 

Sig. Lotion. 
Or, 

^ Liq. plumbi subacet. . . . 5 i. 

Glycerinse 5 ss. ■ 

Aq. laui'O cerasi ^iiiss. 

Sig. Lotion. 
Or, 

Ac. salycil., 

Pulv. boracis aa gr. x. 

Aq O.i. 

M. Sig. Apply to parts affected. 

EMETIC. 
^ Ipecac gr. xxx. 



EMPHYSEMA 0\^ith Asthma ai«d 
Chkonic Bronchitis). 



^ Syr. prun. virg ^iv. 

Spr. (Ether comp. (Hoff .) . . § ss. 

Pot. iodidi 3 ij. 

- Tr. bella 3 ij.-iv. 

M. Sig. 3 i. t. i. d. and send the pa- 
tient- to a warm climate. 
Or, 

^ Pot. chlor 3iss. 

Tr. bella |iss. 

Fl. ext. prun. virg., 

Tr. cinchon. co aa | ij. 

M. Sig. A dessertspoonful 4 times 
a day. 

ENTERITIS. 

]^ Pulv. opii gr. i. 

Plumb, acet gr. ij. 

M. et ft. pulv. i. 

ERYSIPELAS. 

^ Vin. ipecac fl. Jss. 

Sig. gtt. XX. every 2 or 3 hours m 
water. 

Or (Facial). 

R Quin. sulph 3 ss. 

Ext. bella gr- hj. 

M. ft. pil. X. Sig. One every four 
hours. 



EPILEPSY (Idiopathic). 



^ Pot. iodidi. 

Pot. brom aa 3 i. 

Ammon brom 3 ss. 

Pot. bicarb 3ij. 

Inf. calumb | vi. 



M. Sig. I i. before each meal and 3 
tablespoonf uls at bed-time ^vith water. 

ERYSIPSLAS. 
^ Tr. ferri perchlor. , 

Glycerinte il3 5 j- 

Sig. 3 ij. every 2 hours. 



PRESCRIPTIONS. 



FACIAL NEURALGIA. 

!^ Ammon. val gr. v.-x. 

Chi. ammon gr. xxx. 

M. et ft. pulv. Sig. Take immedi- 

^^^^y- FEVER. 

^ Lig. ammon. acetat 5 ij. 

Sp. nit. dulc. 

Syr. ipecac ...53 51. 

M. Sig. 3 i. every 2 hours. 
Or (Malarial). 
^ Quin. sulph 

Fer. sulph. exsie 3i. 

Ac. arseniosi gr. i. 

M, et ft. pil. XX. Sig, One t. i. d. 



F.i:CAL ACCUMULATION. 

R Tr. aloes et myrrh 3 vi. 

Tr. nucis voni 3 ij. 

M. Sig. gtt. XV. -xxx. t. i. d. 

F^CES (Incontinence of). 

^ Tr. bella '3 v. 

Fl. ext. ergotae, 

Aq aa 1 1 j. 

M. Sig. 3 i. t. 1. d. 



422 



PRESCRIPTIONS. 



GASTRITIS (Chkonic). 

1^ Argent, nitratis gr. v. 

Pulv. opii gr. iiss. 

M. et ft. pil. XX. One t. i. d. 

GLEET (In AN.aaiic Peesons). 
^ Tr. fer. perchlor 3 vi. 

Tr. cantharides 31]. 

M. Sig. gtt. XV. in water t. i. d. 

GONORRHOEA. 
^ Sol, plumb, subacet. 

(Goulard's) 3 ss.-i. 

Aq I iv. 

M. et ft. injectio. Sig. Use once 
daily. 
Or, 
5 Copaibas, 

Pulv. cubebae aa f i j . 

Pulv. alum |i. 

Pulv. opii gr. V. 

M. Sig. 3 i.-ij. night and morning. 
Or, 

^ 01. copaibae, 
01. cubebae, 

01. santal. flav aa3i. 

Magnesias 3 ij. 

M. et ft. pil. Ix. Sig. Take two pills 
every 4 hours. 

5 Vin. colch. sem ^ss. 

Sol. pot. cit I viss. 

Tr. opii deodor 3ij. 

M. One tablespoonful t, i. d. 
Or, 

^ Liq. plumb, subacet. diL 5 iv. 

Zincisulph gr. viij. 

M. et ft. injectio. 
Or, 

^ Cad. sulph gr. i. 

Aq liv. 

M. et ft. injectiOc 




Or, 

B Bals. copaibae, 

Sp. nit. dulc aa3i. 

Liq. potas 3ij. 

Fl. ext. glycjrrrh 3 ss. 

Misce et adde : 

01. gaulther gtt. kv. 

Syr. acac ad 5 vi. 

M. Sig. 3 i. t. i. d. 

GONORRHCEA AND GLEET. 

^ Fl. ext. hydrastis 31. 

MucU. acac 3 iv. 

M. et ft. injectio. Sig. Use 5 ss, as 
an injection. 
Or, 

R Fl. ext. hydras 5 ss. 

M .....513. 

M. et ft. injectio. 

GOUT. 

1^ Pil. hydiarg gr. vi. 

Carb. sodii gr. v. 

Ext. col. CO gr. vi. 

M. et ft. pil. i. Sig. Take at bed 
time. 
Or, 

5 Pulv. ipecac, 

Hydrarg, chlor. mite., 
Ext. meUon, 

Ext. colch. acet aa gr. i. 

Ext. nuc. vom gr. 

M. Sig. One pUl every 4 hours ; if 
attack be very bad, 1 in every 2 hours. 
In severe cases, with pain, ^ve gtt. S* 
Magendie's solution. 
Or, 

]^ Vin. colch. rad 3i. 

Pot. bicarb., 

Pot. et sod. tart aa3iiss. 

Aq. menth. pip ^vr, 

M. Sig. 3 iv. t. i. d. 



PRESCRIPTIONS. 



423 



Or, GOUT. 
B Pot. carb., 

Pot. nit aa3iiss. 

Aq : 5 viij. 

M. Sig. Tablespoonful t. i. d. 
Or, 

B Ti'. colch. seminis ttlxx. 

Pot. bicarb gr. x. 

Aq. piment 5 i. 

M. Sig. A draught. 



Or, GOUT. 

^ Tr. colch. sem tti, xv. 

Mag. carb gr. vi. 

Mag. sulph gr. XXX. 

Aq. menth. pip ad § i. 

M. Sig. A draught. 



424 



PRESCRIPTIONS 



HAY ASTHMA. 

^ Pot. iodidi 3 i. 

Liq. pot. arsen 3 i. 

Aq !iv. 

M. Sig. 3 i. every 4 hours. 
Or. 

Liq. pot. arsen 3 iij- 

Tr. bella.... 3 ix. 

M. Sig. gtt. xij. after meals and in- 
crease in 3 days to xvi. and after 10 
days to gtt. xx. 

H.5:MATEMESIS (From Low Con- 
dition). 

^ 01. terebinth 3 iij. 

Fl. ext. dig 3 i. 

Mucil. acac 1 ss. 

Aq. menth. pip li- 

M. Sig. 3 i. every 3 hovirs. 

HEMOPTYSIS. 

5 Plumbi acet., 

Pulv. digit aa3i. 

Pulv. opri gr. X. 

M. ft. pil. XX. Sig. One every four 
hours. 
Or, 

B Fl. ext. ergot 5 iij. 

Fl. ext. ipee., 

Tr. opii deodor aa 5 ss 

M. Sig. 3 i. every hour. 

HEADACHE. 

Fl. ext. guaran 51. 

Hoff. anodyne 3ij. 

Tr. lavand. co 1 vi. 

M. Sig. 3i. eveiy M hour till re- 
lieved. 

Or (Reflex). 

B Pot, cyanid gr. x.-3i. 

Aq. lauro cerasi 3 iv. 

M. Sig. Poii^on. A compress moisL 
ened with the solution to be appUed to 
the seat of pain. 



HEADACHE. 
Or (Severe Continuous). 

B Givehydrarg.chlor.mite.gr. 1-30. 

Every 15 minutes. 
Or, 

B Pot. brom 5L 

Pot. iodidi 3 ij. 

Glycerin ae, 

Syr. rub. idaei aa 5 i. 

M. Sig. 3 i every 3 hours. 
Or (Sick). 
B Ext. gent.. 

Pulv. rhei aa 3 ss. 

Pil. hydrarg gr. iv. 

01. caryophyl gtt. iv. 

31. et ft. pil. XX. 

HEART COMPLICATIONS (In Rheu- 
matism). 

B Pot. bicarb 3 iss. 

Pot. acet 3 ss. 

Pot. nitratis 9i. 

Spts. cether. comp li. 

Ac. citrici 3 i. 

Aq 5 i. 

M, Sig. Take half this mixture 
every hour (making 2 doses). 

HEART (Hypertrophy of). 

B Plumb, acet 3 ss. 

Pulv. opii gr- V, 

Confect. ros q. s. 

M. et ft. pil. XX. One t. i. d. 

HEART LESIONS (with Dilatation). 

R Brom. potas 3 iij- 

Chloral hydrat 31. 

Syr. rub. idaei, 

Aq ail 3 ij- 

M. Sig. 3 i. every hour till relieved. 

HEMIPLEGIA (Due to Syphilis). 

R Pot. iodidi 3 i. (dose). 

Give t. i. d. in half a tumbler of infu- 
sion of hops, and increase the pot. 
iodide till 3 i. t. i. d. be reached. 



PRESCRIPTIONS. 



425 



HEMORRHAGE (Pulmonart). 

B Piumb. acet 3 ss. 

M. et ft. pulv. vj. Sig. One every 3 
hours. 

HEMORRHAGIC DIATHESIS. 

5 Ac. gall 3 ss. 

Ac. sulph. dil., 

Tr. opii deodor aa 3 i. 

Inf. ros. CO 5 iv. 

M. Sig. A tablespoonful everj' 3 
hours. 

HEMORRHOIDS. 

B Pulv. hydras 3 iij. 

Vaseline 3 i. 

Paraffin q. s. 

M. et ft. ungt. Sig. Apply night and 
morning. 
Or, 

R Pulv. gall 3i. 

Pulv. opii gr. X. 

Ung. plumb, subacet — 3ij. 

Ung. simpl 3 i- 

Sig. To be used as directed night 
and morning. 
Or, 

^ Pulv. opii gr. ij- 

01. theobro q. s. 

M. ft. suppos. 1. 

HEPATIC COLIC. 

5 Sodii phos 3 i. 

Sig. Take this amount before each 
meal. 

HYSTERIA. 
R Chloral hydrat 3 iss. 



Pot. brom 3 hj. 

Syr. rub. idaei 5 i. 

Aq. aurant. flav 5 iij. 

M. Sig 3 i. t. i. d. 

HOOPING COUGH. 

H Zinci oxidi 3 i. 

Ext. bella gr. v. 

M. et ft. pil. xxi, Sig. One t. i. d. 



HOOPING COUGH, 

R Syr. ipecac 3 iiss. 

Syr.scillse 3 iij. 

Mist, assafoet ad | ij. 

M. Sig. 3 i.-ij. every 3 hours. 
Or, 

]^ Pot. brom 3 ij. 

Hydrat. chlor 3 ss. 

Ext. bella 31. 

Syr. tolu 5ij. 

M. Sig. 3 i. every half -hour till re- 
lieved. 
Or, 

Camph. monobrom gr. v. 

Syr. tolu 1 i. 

Mucil. acaciae q. s, 

M. Sig. 3 i. as required. 
Or, 

R Ac. nit. dil 3 iij. 

Tr. cardamom, co 5 i. 

Syr. simp 5 iij. 

Syr. cinnamon 5 vi. 

M. Sig. 3 ij. every three houi's and 
let them drink freely of 

IJ Ac. phos. dil. . . 3 i. 

Aq O.i. 

Or (If Severe), 

IJ Fl, ext. hyos 3 ss. 

Aq. aurant 5 iv. 

M.. Sig. 3 i.-iv. every three hours. 

HORRORS. 
^ Pot. brom., 

Aq aa 5 i. 

M. Sig. 3 ij- every 4 hours. 

HYDROPHOBIA. 

R Inf. xanthis spinosi gr. ss. 

M, Sig, Take this amount t. i. d. for 
6 weeks (for adults) ; for children under 
12 years of age, give >i this dose. 



PRESCRIPTIONS. 



INFLAMMATION OF BLADDER. 

R Tr. bella . . . , 3 i. 

Fl. ext. buchu | i. 

Liq. pot. arsen 3 ss. 

Tr. opii camph 3 vi. 

Syr. simp 5iss. 

Aq ad 5 vi. 

M. Sig. 3 i. every 3 hours (tr. opii 
camph. shoiald not be included when 
blood exists in the urine). 
Or, 

^ Pot. brom 3 iij. 

Chloral hydrat 3 iss. 

Syr. rub. idsei, 

Aq aa^i. 

M. Sig. 3 i. every half -hour till re- 
lieved (and apply hot fomentations). 

INFLAMMATION OF BOWELS. 

]^ Pulv. opii gr. i. 

Plumb, acet gr. ij. 

M. ft. pulv. i. 

INDIGESTION. 

^ Cinchon. sulph gr. ij. 

Ext. glj'cyrrh gr. iij. 

Sacchari albi gr. v. 

M. et ft. chart, i. 
Or, 

Sodii bicarb. , 
Pulv. zingib., 

Pulv. calumb aagr. iiss. 

M. et ft. chart, i. 
Or, 

^ Bismuth, subnit gr. xv. 

Ft. chart, i. 

IRITIS. 

^ Morph. sulph gr. iv. 

Zinci sulph gr. iij. 

Atrop. sulph gr. ij. 

Aq. destil 5 i. 

M. Sig. lotio. 

ITCHING (Obstinate). 

■1^ Ac. hydrochlor gtt. xx. 

Aq 5iv. 

M. Sig. Apply to parts. 



IMPOTENCE. 

R Ferri arsen gr. v. 

Ergotine (aq. ext.) ... . 3 ss. 
M. ft. pil. XXX. Sig. Take one night 
and morning. 

INCONTINENCE OF LTUNE. 
B Acid benzoic 3 ij. 

Aq. cinnam 5 vi. 

M. Sig. A tablespoonful t. i. d. 

INCONTINENCE OF URINE AND 
F^CES. 

:i^Tr. bella 3 v. 

Fl. ext. ergot. , 

Aq aa 5 ij. 

M. Sig. 3 i. t. i. d. 

INSOMNIA (From Worry). 

]^ Pot. brom 3 vi. 

M !iij. 

M. Sig. 3i. before each meal and 
take 3 ij. at bed- time. 

INFLUENZA. 

]^ Vin. ipecac ^ rii xvi. 

Tr. opii . .TTi, xiij. 

Spt. eether. nit . 3 i. 

M. To be taken, in wat^r, at bed- 
time. 

Or (Of Old People). 

^ Ammon. carb 3 i. 

Muc. acac fl. 5iv. 

Aq. menth. pip | ij. 

M. Sig. 3 i.-ij. every hour. 
Or (After Loosening of Cough). 

^ Syr. scillae 5 iij. 

Tr. opii camph 5 i. 

M. Sig. 3 i. t. i. d. or 3 ij. at night. 

ITCH. 

Sulph. iodidi 3i. 

Adipis |i. 

M. Apply to the part. 
Or, 

^ Sulphuris 3 i. 

Adipis 5 ij- 

M. et ft. imgt. 



PRESCRIPTIONS. 



437 



JAUNDICE. 

1^ Pot. bitart 1 i. 

Ext. tarax 3 ss. 

Decoct, tarax Iviij. 

M. Sig. Half a wine-glassful t. i 
Or, 

^ Sodii phos dose 3 i.- 5 i. 

For children " gr. x. 

Or (Catarrhal). 
^ Spt. oether. comp. (Hoff.) - • 3 i. 

Sodii bicarb.. gr. x. 

Sig. Take this dose t. i. d. 



JOINTS (Swollen). 
]^ Pot. iodidi 3 i. 

Glycerin li. 

Tr. sap. camph liij. 

01. limonis gtt. iVc 

M. et ft. hoiment. 



428 



PRESCRIPTIONS. 



LABOR (Weabiness or Over-exek- 

TION IN). 

5 Hydrat cliloral gtt. viij. 

Liq. morph. sulph. (Ma- 

gendie) gtt. iij. 

Aq. camph 1 i. 

M. Sig. 3 i. every hour till sleep is 
produced. 

LARYNGITIS. 
R Zinci sulph gr. viij. 

Acidi tannic gr. xx. 

Aq 1 iv. 

M. et ft. gargle. 

LAXATR^E. 

B Mag. carb., 
Mag. sulph., 
Sulphuris loti., 

Sacch. alb aa 3 iv. 

Pulv. anis 3 ij. 

M. et ft. chart, i. 
Or (Cooling). 

R Pulv. ipecac gr. 1-6. 

Pulv. rhei gr. ij. 

Sodii bicarb., 

Pulv. cubeb aa gr. iv. 

M. et ft. chart, i. 

LEUCORRHCEA. 

^ Alum 3 ij. 

M---- 3 viij. 

M. Sig. Inject into vagina bis die, 
LICE (To Destroy). 

5 Hyd. chlor. cor Bi. 

Aq 1 iv. 

M. Sig. Use as a wash. 

LOTION. 

R Liq. plumb., eubacetat 5 j. 

Aquie Oj. 

M. Sig. External application. 



LINIMENT, 

5 Veratriae gr. iv. 

Chlorofonni Ji. . 

Tr, aeon. (Fleming's). . . . . 3 iJ. 

Tr. capsici 583. 

Tr. menth. pip 5 iss. 

01. menth. pip 3 ss. 

M. et ft. lotio. Sig. Poison. 
Or, 

R Fl. ext. aeon. rad. , 

Chlorofonni aa3l. 

Spt. camph 5 ss. 

Lin. sap q. s. lij. 

M. 

LmiR (Enlarged). 

^ Quiniae sulph. . gr. x. 

Pulv. capsici. gr. i. 

Pulv. camph gr. ss. 

M. Sig. Take this dose t. i. d. 
capsule). 
Or, 

R Granules of arsenious 

acid gr. 1-16. 

T. i. d. 
Or, 

^ Warburg's tinct 3 ij. 

T. i. d. for an adult. 

-Warbiu-g's tinct 3 L 

T. i. d. for children. 

LOTION (Red). 

B Zinc suph gr. ij. 

Tr. lavand co itlxr. 

Aq I'u 



PRESCRIPTIONS. 



429 



MALARIAL FEVER. 
First give an emetic, then ; 

^ Quin. sulph 

Ferri sulph. exsic 3i. 

Ac. arsen gr. i. 

M. et ft. pil. XX. Sig. One t. i. d. 
Or (With Cerebral Symptoms). 

^ Quin. sulph gr. v.-x. 

Pot. brom 3 ij.-iv. 

Syr. rub. idaei, 

Aq.. aaji. 

M. Sig. 3 i. every hour. 
Or (In Child 18 Months of Age). 

I)i Quin. sulph gr. xij. 

Lactopeptin gr. xv. 

Hydrarg. submur gr. i. 

M. et ft. chart, vi. Sig. One t. i. d. 
Or (In Pregnancy). 

^ 01. eucalypt. glob gtt. Ix. 

M. (Put into 12 capsules) . Sig. One 
every 3 hours. 

Or (With Vomiting). 

Quin. sulph gr. xx. 

Bismuth, subnit 3 iss. 

(Vel oxalatis cerii .... gr. viij.) 

Morph.. sulph gr. ss. 

M. et ft. chart, iv. Sig. One t. i. d. 

MARASMUS. 

^ Pepsin gr. xxiv. 

M. et ft. pulv. viij. Sig. One t. i. d. 

MASTURBATION. 

^ Pot. brom 3 iv. 

Tr. cinchonse, 

Aq aaliss. 

M. Sig. 3i. t. i. d. 



MENORRHAGIA. 

^ Ferri arsen gr- v. 

Ergotinae (aq. ext.) 3 ss. 

M. et ft. pil. XXX. Sig. One night 
and morning. 

MENSES (Stoppage of). 

^ Pot. brom 3 iv. 

Aq 5ij. 

M. Sig. 3 i t. i. d. 

MERCURIAL POISONING. 

Pot. iodidi gr. x. 

Give t. i. d. 

MILK FEVER. 

Tr. aeon, rad gtt. xx. 

Ant. et pot. tart gr. ij. 

Sp. etheris nit. , 

Syr. simp iia ? i. 

Aq. aurantii flor lij. 

Sig. 3 i. in a vrineglassf ul of water 
(.with sugar) every 2 hours. 

MITRAL REGURITATION. 
I^ Ferri redact., 

Quin. sulph aa 3i. 

Pulv. dig., 

Pulv. scillse aa gr. X. 

M. et ft. pil. XX. Sig. One t. i. d. 

MOUTH (Ulceration of). 

^ Pot. chlor 5 ss. 

Aq 5 vi. 

M. Sig. Tablespoonful t. i. d. 

ivlOUTH WASH. 
^ Sodii bor 3 ij. 

Pulv. myrrh 3 i. 

Aq ...Ivi. 

M. ft. wash or gargle. 



430 



PRESCRIPTIONS. 



NERVOUSNESS (With Debility). 



]^ Pot. brom § i. 

Ferri sulph. exsic 3 ss. 

Calumbas, 

Piilv. zin^riberis aa 3 iv. 

M. et ft. chart, i. 

NEURALGIA. 

^ Aconitin gr, i. 

Stiyehnise gr. iij. 

. Hydrarg. iod gr. vi. 

Adipis ; 3 ij. 

Vermilion. q. s. 



M. et ft. ungt. Rub the affected part 
well with a very small piece of the 
ointment. 
Or, 

Tr. aeon, rad., 

Chlorof ormi aa | ss. 

Lin. sap ll 

M. Sig. Apply to the seat of pain. 
Or, 

IJ Aconitise gr. iv. 

Veratrias gr. xv. 

Glycerin 3 ij. 

Cerati 3 vi. 

M. Sig. To be rubbed over the part. 
Take care there is no abrasion. 



Or, NEURALGIA. 
^ Ext. hyos.. 

Ext. lupuli .'. . aa gr. X. 

Morph. sulph gr. iss. 

M. ft pil. vi. Sig. One night and 
morning. 

Or (Facial). 

^ Ammon. val gr. v.-x. 

Chi. ammon gr. xxx. 

Sig. Take immediately. 
Or (Sacral). 

IJ 01. crotonis 3 i. 

01. amygd. dulc 3 ix. 

M. et ft. embrocatio. 

NOCTURNAL INCONTINCE OF 
URINE IN CHILDREN. 

Strych gr. i. 

Pulv. canthar gr. ij. 

Morph. sulph gr. iss. 

Ferri pulv 3 i. 

M. ft. pil. xl. Sig. One t. i. d. to a 
child 10 years of age. 



OINTMENT (For Sores). 

Zinci oxidi gr. xx. 

Cerati simp., 

Vaseline aa|ss. 

M. et ft. ungt. 



PRESCRIPTIONS. 



PAINS (After Labor). 
^ Sol. morph. sulph (U. S. P.). I j. 
M. Sig. 3 i. every 2 hours till re- 
lieved. 

PERIOSTITIS. 
Give pot. iodidi gr. v. to commence 
with, and increase gradually to gr. 

XXX. 

PERITONITIS (Local). 

^ Morphias gr. i. 

Camphoree gr. xij. 

Pulv. sacch. alb gr. xxiv. 

M. et ft. chart, vi. Sig. One every 
3 hours till relieved . and apply flaxseed 
poultice. 

PERITONEUM, INFLAMMATION 
OF, AND OTHER INFAMMATORY 
CONDITIONS. 

^ Tr. aeon, rad 3 i. 

Adipis 3 iij. 

Chlorof ormi 3 i. 

Morph. mur gr. vi. 

M. ft. linctus. Sig. Apply on cotton 
wadding to a small surface only. 

PLEURISY (Acute). 
B Hydrarg. chlor. mit .gr. vi. 

Pulv, opii gr. iij.-vi. 

Antimon. tart gr. iss, 

M. et ft. pulv. xij. Sig. Take one 
every 3 hours in water. 
Or (Subacute). 
B Pot. acet. , 

Inf. digital aa 3 ij.-iv. 

Sig. This amount each day. 
Or, 

R Pulv. dig., 

Pulv. scillae mer., 

Hyd chlor. mit aa gr. x. 

M. et ft. pil. x. Sig. One pill t. i. d. 



431 

PLEURISY. 
Or (Pain). 

B Tr. aeon, rad 3 i. 

Adipis 3 iij. 

Chlorof ormi 3 i. 

Morph. mur gr. vi. 

M. ft. linctus. Sig. Apply on cotton 
wadding to a small siu-face only. 

PNEUMONIA (Caseous). 

^ Inf. dig 5 iv. 

Plumbi acet 3i. 

Tr. opii 3 i. 

Sig. A tablespoonful bis die. 
Or (Typhoid). 
B Ammon. carb 3 i. 

Muc. acac fl. 5iv. 

Aq. menth. pip f ij. 

M Sig, 3 i.-ij. every hour. 

PREGNANCY (Vomiting op). 
R Bismuth, subnit 3 iij. 

Ac. carbol gr. ij,-iv. 

Muc. acac 5 i. 

Aq. menth. pip. . . . . 5 iij. 
M. Sig. 3 ij. t. i. d. 
Or (Vomiting of). 

R Cerii oxalat., 

Pulv. ipecac Sagr. i. 

Creasoti gtt. ij. 

M. et ft. pulv. Sig. To be taken 
every hour. 

Or (Sick Stomach of). 

5 Rad. calumbo, 

Rad. zingiber aa 5 ss. 

Fol. sennas 3 i. 

Aq. bullient O.i. 

M. Infus. Sig. A wineglassful be- 
fore each meal. 

PILES OR HEMORRHOIDS. 

R Pulv. opii gr. ij. 

01. theobrom q, s. 

M. et ft. suppos. 1. 



433 



PRESCRIPTIONS. 



PHTHISIS. 

:^ 01. morrh 11 

Tr. iodinii co triviij. 

M. Sig. 3 i.-iv. every 3 hours. 
Or, 

]^ Mist. ol. morrh 5 i. 

./Etheris ^xvi. 

Or, 

]^ Ac. carbol 3 iij. 

01. gaulther gtt. xx. 

Glycerin li. 

Spts. alcohol 1 ss. 

Aq ad I viij. 

M. Sig. Put one tablespoonful in 
O.ss. water and inhale the vapor. 
Or, 

1^ Sulph. morph gr. i. 

Syr. bals. tolu, 

Syr. prtm. Virg aa 5 i. 

M. Sig. 3 i. t. i. d. If there be night- 
sweats add: 

Morphine gr. 1-60. 

Or, 

Sulph. morph gr. i. 

Vini antimon 3 ij. 

Syr. tolu I iss. 

Aq 5 iij. 

M. Sig. 3 i. every 3 hours. 
Or (Aphtha of). 

]J Quin. sulph gr. i. 

Olei piperis nig gtt. i. 

Aq !i. 

Sig. Apply with a brush or rinse out 
the mouth. 

Or (Fibroid). 

^ Fl. ext. ergotae, 

Tr. hyos aa3iv. 

M. Sig. gtt. XX. t. i. d. 
Also, 

^ Protagon 5 i. 

Glycerin 5ij. 

M. Sig. 3 ss. after each meal. 



PHTHISIS. 
Or (Troublesome Cough), 
^ Syr. prunis Virg. , 

Syr. laetucarii aa 5 ij. 

M. Sig. One or two dessertspoon- 
fuls at night or 3 ij. during the day. 
Or (When Temperature Rises 
Above 100°). 
Fl. ext. gelsemii. 

Tr. ver. vir aa3i. 

Tr. aeon, rad 3 ij. 

Tr. digitalis 3 iij. 

M. Sig. gtt, vij. t. i. d. If irregular 
ity of pulse exist, omit the digitalis, 

PROSTRATION (General). 
1^ Ammon. carb 3 i. 

Muc. acac fl, §iv. 

Aq. menth. pip 1 ij. 

M. Sig. 3 i.-ij. every hour, 

PUERPERAL CONVULSIONS. 

]^ Chloral hydrat : iij. 

Syr. rub. idaei 3 i. 

M. Sig. 3 i. every 20 minutes. 

PURGE. 

B Pil. hydrarg gr. vi. 

Sodii bicarb gr. v. 

Ext. coloc. CO gr. vi. 

M. Sig. To be taken at bed-time. 

PRURITUS. 

^ Ac. carbol 3 i.-ij. 

Glycerin § i. 

Aq adjviij. 

M. Sig. Use as a lotion. 

PRURITUS ANI. 
1^ Pot. brom., 

Chi. hydrat aagr. x.-xv. 

Aq adri. 

M. Sig. To be taken at bed-time. 



PRESCRIPTIONS. 



Also, PURITIS ANI. 



^ Sodii bibor 3 ij. 

Morph. mur gr. xvi. 

Ac. hydrocyan. dil 5 ss. 

Glycerin lij. 

Aq ad^viij. 

M. Sig. To be applied to the affected 
part. 

PROSTITIS WITH CYSTITIS. 

^ Tt. hyoBcyam § i. 

Potass, bicarb 3iij. 

Aqax ^iij. 



Mi Sig. 3 iv, t. i. d. 



Or, PRURITIS ANI. 

1^ Chloroformi 3 ij. 

Glycerin | ss. 

Cerat. simp 5 iss. 

M. et ft. ungt. Apply locally. 



434 



PRESCRIPTIONS. 



RHEUMATISM (Acm-E). 

B Ac. salicyl 3iij. 

Sodii bicarb .... . 3 ij- 

Glycerinae, 

Aq aa§ij. 

M. Sig. A. tablespoonful every two 
hours. 

Or (Chronic). 

5 Tr guaiac 

Sig . 3 i. t. L <L in water. 



RHEUMATIC PAINS. 
R Lin. aeon., 

Lin. bella aasij. 

Glycerinae ad 

Sig. • Appl;- locally over seat of pain. 

RUM STOIHACH. 
^ Tr, nuc. vom gr. v.-xv. 

Tr. gent, co., 

Tr. calumbae co. . .aa3 i. 
Sig. Take before meals. 



PRESCRIPTIONS. 



435 



SMALL-POX (To Prevent Pitting). 



^ Pulv. carb. lig 1 ss. 

Oi. picis, 

Cerati simp aa 5 ij . 

Syracena purpura ^ss. 



M. et ft. ungt. Sig. Rub over all 
parts that are exposed. 

SPRAIN. 

R Liq. plumb, subacet. dil. 3iss. 

Morph. acet 3i. 

Aq §viij. 

M. et ft. lotio. Sig. For external 
application. 
Or, . 

^ Lin. sapon 5 iv. 

Aqiije ammon 3 ss. 

M. et ft. embrocatio. 
Or, 

ifi Chloroformi. fl. 3 ij. 

Tr. aeon, rad., 

Aq. ammon aa fl. 3 ss. 

01. olivaB fl . 3 V. 

M. Sig. Liniment for external ap- 
plication. 

Or (Of Ligaments). 

First place the limb for five minutes 
in a hot salt and water bath, then ap- 
ply: 
R Chloroformi, 
Tr. aconiti, ' 

Tr. opii aa3iij. 

Lin. sap 5 iv. 

M. et ft. lotio. Sig. To be used as 
directed. 

SEDATIVE. 
R Pot. brom., 

Sp. ammon. arom aa 3 ij. 

Syr. scLl]3e..i.., li. 

Aq 5iij. 

M. 



SPERMATORRHCEA. 

j R Ferri arseniat gr. v. 

I Ergotinas (aq. ext.) 3 ss. 

M. et ft. pil. XXX. Sig. One night 
and morning. 

Or (With Impotence). 

R Tr. canthar gtt. vi. 

Tr. ferri perchlor . . gtt. xv.-xx. 
Sig. t. i. d. in water. 

SPLEEN (Enlarged). 
(See liver enlarged.) 

SWELLING OF JOINTS. 

R 01. sassafras 3 ij. 

Aq. ammon 3 iv. 

Lin. sap. camph 5iij. 

M. ft. liniment (for external applica- 
tion). 

SICK HEADACHE (Due to Gastri- 
tis). 

R Pulv. calumbte, 

Bismuth, subnit aagr. x. 

M. Sig. Take this t. i. d. after 
meals. 
And, 

R Inf . cinchon ^ss.-ij. 

Take this before meals t. i. d. 

SICKNESS OF STOMACH. 

R Bismuth, subcarb gr. xxx. 

Ingluvin gr. xx. 

M. et ft. pulv. V. (for adult). Sig. 1 
t. i. d. 

I SKIN DISEASES. 

R Liq. pot. arsen 5 ss. 

Sig. gtt, V. t. i. d. 
Or (Due to Syphilitic Origin). 
^ Liq. arsen. et hyd. iodidi.. 5 ss. 
Give TTi ij.-v. t. i. d. 

SKIN ERUPTIONS. 

R Ungt. hyd. nit. mit 5ss. 

Sig. For external application. 



436 



PRESCRIPTIONS. 



SYPHILIS. 

]^ Hyd. protiodidi gr. xij. 

Rosffi confect 3i. 

M. et ft. pil. xij. Sig. Take one bis 
die. 

Or (Constitutional). 

1^ Pot. iodidi 5 ss. 

Aq. cinnamomi § i. 

M. Sig. 3 i. t. i. d. 
Or, 

R Pot. iodidi gr. xx. 

Hyd. chlor. cor gr. 1-6. 

Aq. cinnam 5i. 

M. Sig. 3 ij.-iv. every 3 or 4 hours. 
Or, 

R Hyd. chlor. cor gr. H. 

Pot. iodidi gr. Ixxx. 

Aq. menth. pip 5 i. 

M. Sig. 3 i.-ij. every 3 or 4 hours. 
Or (Secondary). 
R Liq. arsen. et hydrarg iodid. I ise. 
Sig. gtt. iij.-v. t. i. d. 

Or (2d and 3d Stages). 

^ Hydr. bichlor gr. ij. 

Pot. iodidi 1 ss. 

Pot. chlor 3 i. 

Tr. gent, co., 

Aq ..aa^iv. 

M. Sig. 3 i. t. i. d. after meals." 
Also, 

1^ Pil. hyd. prot gr. ss. 

In the middle of the day. 
Or (Infantile). 
^ Hydrarg. bichlor gr. i. 

Pot. iodidi 3 iv. 

Syr. aurant., 

Aq aa3 ij. 

M. Sig. gtt. V. for child about one 
month old and increase to xv.-xx, if 
the disease does not yield. 



SCROFULA. 

I^ lodini — 2 vi. 

Pot. iodidi (troy) § iss. 

Aq. destil O.i. 

M. Sig. gtt. v.-vi. bis die, in water. 
Or, 

^ Syr. fer. iodidi fl. 3 ss. - 

Sig. gtt. x.-xx. in water t. i. d. 

SORE NIPPLES. 

R Plumbi nit gr. x.-xx. 

Glycerin li. 

Sig. Rub on the affected part. 
Or, 

Aqu« rosas 3 Liiss. 

Liq. plumb, subacet. dil. | ss. 

Ext. opii aq 31. 

Sig. Lotion. First apply a bread 
and milk poultice to the parts, and 
after removal, apply a piece of linen 
of two thicknesses, after being wetted 
with the lotion. 

SORES (Bad). 

^ Ac. carb: gr. ij, 

Aq O.i. 

M. et ft. lotio. 
Or (Bed). 

15^ Alum § ss. 

Tr. camph |ij. 

Add the white of four eggs. M. Sig. 
Apply to the parts affected. 

STOMACHIC. 

R Ac. nitro-mur. dil tti;x1. 

Inf. gent, co ^i. 

M. Sig. 3 ij. every 3 or 4 hours. 
Or, 

^ Liq. pot. arsen 2 ss. 

Tr. quassise 3ij. 

Syi-upi 3 vss. 

M. Sig. 3 i. (diluted) immediately 
after meals. 



PRESCRIPTIONS. 



437 



SUNSTROKE. 

Hydr. bichlor gr. i. 

Pot. iodidi gr. viij. 

Aq ?iiss. 

M. Sig. 3 i. t. i. d. 



STRYCHNIA POISONING. 

^ Nicotinae gr. ss. 

Aq. dest 313. 

M. Sig. Give TTi x. as occasion re- 
quires. 



438 



PRESCRIPTIONS. 



TAPE WORM. 
^ Insert a tube down the oesophagus 
to the stomach and pour down it from 
200 to 400 centigrammes of a very con- 
centrated decoction of pomegranate 
root, and let the patient fast for 24 
hours. 
Or. 

Let him drink soda water ad lib. 
TONIC. 

9 Sulph. sti-ych -gr. i. 

Ferri pyrophos., 

Quin. sulph aa 3 i. 

Ac. phos. dil., 

Syr. zingiber aa|ij. 

M. Sig. 3 i. t. i. d. 
Or, 

5 Ferri sulph gr. ij. 

Mag. sulph 3 iss. 

Ac. sulph. dil TTlxv. 

Inf. quassias li. 

M. Sig. Tablespoonful every three 
hours. 
Or, 

Vin. feiTi . 3ii3- 

Liq. pot. arsen 3 ss. 

Syrupi 3 iss. 

Aq 3iij. 

M. Sig. A tablespoonful diluted, 
after meals. 
Or, 

]^ Ferri et quin. cit 3 ss. 

Syr. simp 3 ij. 

Aq... ^vi. 

M. Sig. 3i. t. i. d. 
Or, 

B Quin. sulph gr. x. 

Ac. sulph. dil q.s. 

Glycerin 3ij. 

Aq ad^i. 

M, Sig. 3 i. t. i. d. 



Or TONIC. 

R Cinch, sulph 3i. 

Tr. ferri chlor i 3 iv. 

Tr. quas 3 i. 

Aq ad^iv. 

M. Sig. 3 i. t. i. d. 
Or, 

5 Liq. pot. arsen 3ij. 

Vini ferri ad^iv. 

M. Sig. 3 i. t. i. d. in a \\ineglass of 
water after meals . 
Or (Chalybeate). 

R Ferri phos 3 i. 

Divide in chart, xij. Sig. Take one, 
in water t. i. d. 

TONIC AND ALTERATIVE. 

B 01. phosphor lUxvi. 

01. gaulther. ^viij. 

Muc. acac 5 i. 

M. Sig. 3 i.-ij. every 3 hours. 
Or, 

B Pot. chlor 3 ss. 

Tr. ferri chlor 3 i. 

Aq 3 vij. 

M. Sig. 3 i. eveiy 3 hours. 

TONIC AND SOOTHING. 

B Ext. nuc. vom gr. iv. 

Ext. hyos gr. XV. 

Pulv. aloes, 
Quin. sulph., 

Ferri sulph aaBi. 

M. et ft. pil. XX. Sig. Take one 
twice a day. 

TONSILLITIS. 

R Vin. ipecac fl. 5ss. 

Sig. gtt. XX. every 2 or 3 hours in 
water. 
Or, 

R Quin. sulph gr. x.-xx. 

Give twice a day. 



PRESCRIPTIONS. 



439 



Or TONSILLITIS. 

Tr. guaiac 5 

Yolk of egg. 
M. Sig. 3 ss. every 4 hours. 
Or, 

^ Pot. chlor., 

Alum a,a3ij. 

Ext. bella 3iv. 

Glycerin., 

Aq. rosae aa § i j. 

M. et ft. garg. Sig. Use four times 
daily. 

TORPOR OF INTESTINES. 
I^ Ext. physos., 

Resin, podoph aa gr. iij. 

M. et ft. pil. vi. Sig. Take one at 
bed-time. . 
Or, 

IJ Tr, physost., 
Tr. nuc. vom., 

Tr. bella aa3 ij. 

M. Sig. gtt. XXX. in water night and 
morning. 



THROAT (Ulceration of). 

]^ Pot. chlor iss. 

Aq 5vi. 

M. Sig. Tablespoonful t. i. d. 

typh:^itis. 

^ Pulv. opii, 

Pulv. ipec aa gr. vi. 

M. etft. pil. xij. One every three 
hours. 

' TYPHOID PNEUMONIA. 

^ Ammon. carb 3 i. 

Muc. acac fl. 5iv. 

Aq. menth. pip | ij. 

M. Sig. 3 i--ij. every hoiu-. 

URINE (Incontinence op). 

^ Tr. bella 3 v. 

Fl. ext. ergot., 

Aq .aalij. 

M. Sig. 1 i. t. i, d. 



URETHRITIS. 

^ Copaibas 5 '• 

Pulv. acac 3 iij 

Mix Avell and add 

Liquor potass 3 ii^s. 

Glycerinse, 

Spts. nit. dulc aa ^iss. 

Sig. 3 iv. t. i. d. 



PRESCRIPTIONS. 



440 

VAGINITIS. 

IJ Ac. carbol 2 ss. 

Glycerinae 

Cerati simp aaji. 

M. et ft. ungt. 
Or, 

^ Ac. carbol. 3 i. 

Ung. zinci ox 5 i. 

Or, 

B Ac. tannici gr. xxx. 

Adipis.... 5i. 

Or, 

Camph., 

Chloral hydrat aa 3 ij. 

Aq. rosae . . 1 iv. 

M» et ft. lotio. 

VARICOSE VEINS. 
^ lodini gr. i. 

Pot. iodidi 3 iiss. 

Tr. aurant. co., 

Tr. cincli. co aa 3 i. 

Aq ad^ij. 

M. Sig. 3i. t. i. d. 

VOMITING. 

^ Sodii bicarb 3iv. 

Spt. cetliercomp. (H<)ff.) . . 3 i. 

Morph. Sulph 3 iiss. 

Aq. cinnamom ad 5 iv. 

M. Sig. Take one or two teaspoon- 
fuls at once. 

Or, 

R Oxalat. cerii gr. xxxv. 

Lactopeptin gr. xxx. 

^ M. et ft. chart, vi. Sig. One every 
2 hours till relieved. 



VOMITING. 
- Or (Op Pregnancy). 

R Ingluvin gr, xx. 

Oxalat. cerii gr. xxv. 

M. et ft. chart, vi. Sig. One every 
4 hours. 

Or (Of Pregnancy). 

^ Cup. sulph gr. ij. 

Aq. destil ^ ss. 

M. Sig. gtt. vi. t. i. d. 

Or (Of Pregnancy). 

5 Bismuth, subnit. ..... 3 iij. 

Ac. carbol gr. ij.-iv. 

Muc. acac , 5 i. 

Aq. menth. pip 5 iij. 

M. Sig. 3 ij. t. i. d . 
Or (Of Pregnancy). 
R Cerii oxalat gr. i. 

Ipecac gr. L 

Creasoti gtt. ij. 

Sig. To be taken every hour. 
Or (Of Teething). 
5 Bismuth, subnit 3 iij. 

Ac. carbol gr. ij.-iv, 

Muc. acac 5 i. 

Aq. menth. pip 5 iij. 

M. Sig. 3 i. (small, foF a child) t. 

i.d. 

Or (Of Teething) 

Bismuth, subcarb 3 ij- 

Morph. sulph gr. ss. 

M. et ft. chart, vi. Sig. One t. i, d. 

in milk. 



PRESCRIPTIONS. 



441 



WAKEFULNESS (From Worry). 



^ Pot. brom 3 vi. 

Aq 5iij- 

M. Sig. 3 i. before each meal, and 
take 3 ij. at bed-time. 

WORMS. 

H Santonini gr. i. -ii j . 

Sacchari albi gr. ij. 

Ft, chart, i. 



Or (Round and Ascaris Vermicu- 

LARIS). 

Fl. ext. spigeliae, 

Fl. ext. sennae aa 5 ss. 

M. Sig. 3 i. to a child 3 or 5 years of 
age. 

Or, 

^ Fl. ext. spigelise, 

Fl. ext. sennae aa 3 ss. 

Santonini gr. vuj. 

M. Sig. 3 i. to a child 5 years of age. 
Or 

5 Hyd. chlor. mit gr. xxx. 

Santonin gr. xij. 

M. et ft. pulv. vi. Sig. One t. i. d. 
Or, 

^ Pulv. santon .gr. x. 

Hyd. chlor. mit gr. iij. 

■Res. jalapse gr. i. 

Saccb. lactis . .gr. xx. 

M. et ft. chart, vi. Sig. Onet. i. d. 



WHOOPING COUGH. 



ijt Syr. ipecac . . 3 iiss. 

Syr. scillse 3 iij. 

Mist, assafoet ad 5 ij. 

M. Sig. 3 i.-ij. every 3 hours. 
Or, 

^ Zinci oxidi 31. 

Ext. bella gr. v. 

M. et ft. pil. xxi. Sig. One t. i. d= 
Or, . 

Ac. nit. dil 3 iij, 

Tr. cardamom, co li. 

Syr. simp 5 iij. 

Syr. cinnam 5 vi. 

M. Sig. 3 ij. every 3 hours, and let 
them drink freely of : 

Phos. acid 31. 

Aq O.i 

Or, 

^ Pot. brom. 3 ij- 

Hydrat. chloral 3 ss. 

Ext. bella 31. 

Syr. tolu 5ij. 



M. Sig. 3 i. every half-ho\ir till re- 
lieved. 
Or, 

]^ Camph. monobrom gr. v. 



Syr. tolu li. 

MucUd. acac q. s. 

M. Sig. 3 i. as required. 
Or (If Severe). 

^ Fl. ext. hyos 3 ss. 

Aq. aurant liv. 



M. Sig. 3 i.-iv. every 3 hours. 



DISINFECTANTS. 

For Privies:— 

Dissolve a pound of sulphate of iron in a gallon of water; or 
mix thoroughly in water the same quantity of chloride of 
lime. 

For Water-closets, Bed-pans, etc.: — 

Use Labarraque's solution of chlorinated soda, a fluid ounce 
to a quart of water; or permanganate of potassium (the crude 
permanganate is much cheaper than the crystallized and will 
answer equally as well), ten grains to a quart; or carbolic 
acid, twenty grains to the pint or quart. Tar is a very good 
disinfectant. 

For Drinking-water: — 

After filtering, add sufficient permanganate of potassium to 
make it of a pinkish color in a strong light. 

For Articles of Clothing, etc. : — 

If much soiled from the discharges of patients, they should be 
burned or boiled thoroughly. Use a solution of pey^manganate 
of jDotassiiun, on-e ounce to three gallons of water. Expose 
for several hours to a dry heat of from 200° to 250° F., all 
woollen articles and bedding which cannot be washed. 

For Occupied Rooms and Houses: — 

Ventilate freely and diffuse by spray through the air Ledoyen's 
liquid solution of nitrate of lead ; or solid chloride of lime 
may be placed in shallow vessels, or sprinkle -one-per-cent 
solution of carbolic acid. Whitewash the cellars. Charcoal 
and quicJdime, especially charcoal, absorb gas, and thus aid 
in purifying the air. - 

For Hospital Wards: — 

Disinfect, ventilate, and cleanse well with Ledoyen's liquid, 
or with chloride of lime, or bromine may be left exposed to 
the air in shallow vessels, or iodine moderately heated. 

For Heaps of Filth, Solid or Semi-liquid:— 

Cover with charcoal two or three inches deep, or with dry 
^ earth. 

For Drains, Ditches, and Sewers:— 

Disinfect with sulphate of iron, coal-tar, or chloride of lime. 
A pound of good chloride of lime will be sufficient for a 1,000 
gallons of running sewage. 



POISONS AND THEIR ANTIDOTES. 



NEUEOTIC POISONS. 



Poisons. 
Aconite. 



Alcohol. 



Atropia and Bella- 
donna. 



Calabar Bean (physos- 
tigma.) 



Cannabis Indica. 

Chloral. 

Conium. 
Digitalis. 
Dulcamarra* 



Antidotes. 
After thoroughly emptying the stomachy 
diffusible stimuli must be used both 
inwardly and outwardly (especially 
alcohol). 

Stomach-pump ; emetics ; cold alfusions ; 
counter irritants ; strong coftee ; artifi- 
cial respiration ; electro-magnetism ; 
hypodermic injections of atropia. It 
is better to administer ammonia as it is 
the physiological antidote. 

Stomach-pump ; emetics (especially sul- 
phate of copper in ten grain doses) ; 
cathartics ; cold affusions ; hypodermic 
injections of a morphia salt; magnet- 
ism; stimulants. 

Stomach-pump ; emetics ; cold affusions; 
counter irritation ; strong coffee ; hy- 
podermic injections of atropia ; arti- 
ficial respiration ; magnetism. 

Stomach-pump ; strychnia (hypodermic- 
aUy) ; vegetable acids ; vinegar ; hot- 
spirits and water. 

Same as Calabar Bean. Do not use arti- 
ficial respiration. Physiological anti-^ 
dote is strychnia. 

Same as Aconite. 

Same as Aconite. 

Same as Belladonna, 



444 POISONS 

Hydrocyanic Acid 
and Cyaniaes 

Hyoscyamus. 
Lobelia. 

Oil of Bitter Almonds. 
Opium or Morphia. ♦ 
Stramonium, 
Strychnia. 



Tobacco. 
Veratria. 
Veratrum Viride 



AND THEIR ANTIDOTES. 

Ammonia ; chlorine ; cold affusions ; 
fresh au' and artificial respiration. 

Same as Belladonna. 
Same as Aconite. 
Same as Hydrocyanic Acid. 
Same as Calabar Bean. 
Same as Belladonna. 

Tannic acid ; opium ; conium ; extract 
of hemp ; camphor ; chloral ; calabar 
bean ; bromide of potassium ; inhala- 
tions of ether or chloroform; atropia. 

Same as Aconite. 

Same as Strychnia, 

Same as Aconite, 



Poisons. 
Acids (mineral and 
vegetable). 

Alkalies. 
Alum. 

Arsenious Acid. 

Baryta and its Boluble 

salts. 

Bichiomate of Potas- 



CORROSIVE POISONS 
Antidotes. 
Magnesia ; chalk ; alkaline solutions 



fixed oils ; carbonate of soda, 
use emetics. 



Do not 



Citi'ic acid ; lemon juice ; vinegar ; oils. 

Carbonates of ammonium or sodium. 

Hydrated magnesia ; hydrated sesqui- 
oxide of iron ( 3 i doses). 

Sulphates of magnesium, sodium, or 
potassium. 

Alkaline carbonates ; soap ; magnesia. 



Chromium compounds. Chalk or magnesia compounds ; emetics. 



POISONS AND THEIR ANTIDOTES. 



445 



Corrosive sublimate 
and soluble mer- 
curial salts. 

Cream of Tartar. 

Nitrate of Silver. 

Salt of Sorrel. 

Soluble Arsenites. 

Soluble Cupric Salts. 

Soluble Lead Salts. 



Soluble Zinc Salts 



White of egg ; milk ; flour ; — for cupric 
salts also ferrocyanide of potassium. 

Sodium carbonates in solution. 
Chloride of sodium. 
Salts of calcium. 
Ferric subacetate. 

Same as Con-osive, Sublimate and 
Soluble Mercurial Salts. 

Alkaline or soluble earthly sulphates ; 
diluted sulphuric acid;emetics (for after 
treatment milk and opium should be 
given). 

Albumen ; magnesia : sodium carbonates; 
emetics ; demulcents (warm). 



Sulphates and Chloride Alkaline carbonates, 
of Iron. 



Tartar Emetic. 



Tannic acid ; catechu or any vegetable 
acids. 

IRRITANT POISONS. 

Antidotes . 
Salts of iron (dyalized iron) ; magnesia ; 
lime and astringents ; artificial repira- 
tion ; ammonia ; charcoal ; cold affu- 
ions. 

Arsenic (in solution) Freshly precipitated hydrated sesqui-ox- 
ide of iron. 



Poisons, 
Arsenic. 



Asphyxiating Gases. 
Bromine. 



Cold affusions ; artificial respiration 
magnetism. 

Ammonia. 



4 18 POISONS AND THEIR ANTIDOTES. 

Cantharides. 



Carbolic Acid. 

Chlorine Gas. 

Chlorine Water and 
solutions of Chlorin- 
ated lime. 

Chloroform. 



Emetics; opiates (which may be given 
either by mouth or rectum) and 
demulcents. 

Substances of an albuminous, mucilagi- 
nous or oleaginous nature. 

Cautious inhalation of ammonia. 

Albumen given freely in the form of 
milk, eggs, flour, etc. 

Artificial respiration ; cold affusions ; 



Colchicum, 

Creosote. 
Croton Oil, 



Drastic Cathartics. 
Iodine. 



Paris Green 
(arseniate of copper). 

Phosphorus. 



Tannic acid ; emetics ; demulcents. 
Should symptoms of coma come on ad- 
minister ammonia, brandy, coffee. 

Same as Carbolic Acid. 

Sulphate of copper (in gr. x. doses), to 
produce emesis, which should be fol- 
lowed by mucilaginous drinks con- 
taining opium. 

Demulcents ; opiates ; stimulants. 

Starch or flour-water 
emetics. 

Same as Arsenic, 



demulcents ; 



Magnesia ; oil of turpentine (old) ; 
emetics ; purgatives. 



INDEX. 



Abdominal pain, causes of, 20. 

typhus fever, 281. 
Abnormal state of the blood 

classified, 16. 
Abscess, retro-pharyngeal, 165. 
Acclimative fever, 296. 
Addison's disease, 395. 
African fever, 280, 296. 
Albuminous urine, causes, of 33. 
Alcohol poisoning, 260. 
Amyloid kidney, 377. 

liver, 218. 
Anaemia of the brain, 227. 
Angina Ludovici, 164. 

pectoris, 145. 
Aortic obstruction, 116. 

regurgitation, 118. 
Apex-beat of heart, causes of 

displacement of, 20. 
Aphonia, causes of, 28. 
Aphthse, 152. 
Apoplexy, 229, 259. 

cerebral, 229, 256. 
heat, 255. 
pulmonary, 69. 
Ardent fever, 280. 
Arthritis, 343. 
Ascaris lumbricoides, 197. 
Ascites, 212. 

causes of, 26. 
Asiatic cholera, 192. 



Asphyxia, 259. 
Asthma, 56. 
Ataxia, locomotor, 251. 
Autumnal fever, 261. 

Basedow's disease, 147. 
Basilar, meningitis, 238. 
Bilious fever, 296. 

remittent fever, 298. 
Bladder, diseases of the, classi- 
fied, 15. 

Blood, abnormal states of the, 
classified, 16. 
in urine, causes of, 30. 
Bloody-flux, 189. 
Bothriocephalus latus, 197. 
Brain, anaemia of the, 227. 

dropsy of the, 238. 
Break-bone fever, 285. 
Bright's disease, 367. 
Bronchi, diseases of the, classi- 
fied, 13. 
Bronchial hemorrhage, 71. 
Bronchitis, 47. 

acute capillary, 50. 
acute catarrhal, 48. 
chronic catarrhal, 
52. 

croupous, 55. 
plastic, 55. 
Bronchopneumonia, 80. 



448 



INDEX. 



Buccal cavity, diseases of the, 
classified, 10. 

Calculi, renal, 392. 
Calenture, 255. 
Camp fever, 291. 
Cancer of the liver, 216. 

of the lungs, 74. 

of the pericardium, 110. 

renal, 394. 
Cancrum oris, 153. 
Caput Medusae, 211. 
Carcinoma of the intestines, 
193. 

of the stomach, 173. 
Cardiac dilatation, 135. • 

hypertrophy, 132. 

murmurs, 130. 

thrombosis, 143. 
Catalepsy, 259. 

Causes of abdominal pain, 20. 
of aphonia, 28. 
of albuminous urme, 33. 
of ascites, 26. 
of blood in urine, 30. 
of cerebral hyperaemia, 

225. 
of chill, 23. 
of chylous urine, 34. 
of coma, 26. 

of displacement of apex- 
beat of heart, 20. 

of dyspnoea, 24. 

of epigastric pulsation, 
19. 

of haemoptysis, 27. 
of headache, 23. 

of Hepatic abscess, 34. 



Causes of hemiplegia, 29. 

of hemorrhage from the 

digestive tract, 27. 
of instantaneous death, 

31. 

of jaundice, 25. 
of pain in the thorax, 31. 
of paraplegia, 29. 
of pus in urine, 31. 
of retention of urine, 30. 
of suppression of urine, 
30. 

of vomiting, 22. 
Cerebral apoplexy, 229. 

compression, 258. 
concussion, 258. 
hyperasmia, 225. 
softening. 248. 
typhus fever, 291. 
Cerebro spinal meningitis, 
24g. 

ChiQ, causes of, 23. 
Chylous urine, causes of, 34. 
Cholera, Asiatic, 192. 

morbus, 184. 
Cirrhosis of the hver, 210. 

pulmonaiy, 82. 
CiiThotic kidney, 381. 
Classification of aV normal states 

of the blood, 16. 
Clergyman's sore throat, 40r 
CUmatic fever, 280. 
Colic, flatulent, 200. 

hepatic, 219. 

intestinal, 199. 

lead, 200. 
Chorea. 397. 



INDEX. 



449 



Coma, causes of, 26. 

its principal causes and 
differential diagnosis, 
258. 

Congestion, renal, 359. 
Congestive fever, 280. 
Continued fever, 291, 296. 
Coup de soleil, 255. 
Cranial cavity, diseases within 

the, classified, 9. 
Croup, pharyngeal, 164. 

p s e u d o -membranous, 
345. 

Dandy fever, 285. 
Dengue fever, 285. 
Diabetes, 336. 

insipidus, 338. 

mellitus, 336. 
Diarrhoea, types of, 33. 
Digestion, organs of, classified, 
10. 

Diphtheria, 345. 
Diphtheritis, 345. 
Disease, Addison's, 395. 

physical signs of, 4. 
rational signs of, 3. 
Diseased condition of the body, 
9. 

Diseases of the bladder, classi- 
fied, 15. 
of the bronchi, classi- 
fied, 13. 
• of the buccal cavity, 
classified, 10. 
of the digestive tract, 
151 



Diseases of the heart and peri- 
cardium, classified, 
14. 

of the intestinal canal, 
classified, 12. 

of the intestines. 181. 

of the kidney, classi- 
fied, 15. 

of the larynx, 37. 

of the larynx, classi- 
fied, 13. 

of the liver, 210. 

of the liver, classified, 
12. [14. 

of the lungs, classified. 

of the mouth, 151. 

of the nervous system, 

classified, 9. 
of the oesophagus, 166. 

of the oesophagus, 
classified, 11. 

«f the pericardium, 
103. 

of the pharynx, 164. 

of the pharynx, classi- 
fied, 10. 

of the pleura, classi- 
fied, 14. 

of the stomach, 169. 

of the stomach, [[classi- 
fied, 11. 

within the cranial 
cavity, classified, 9. 

within the spinal cord, 
classified, 9. 
Dothenenteria fever, 261. 
Dysentery, 189. 



450 



IHDEX. 



Dyspepsia, 176. 


Fever, dandy, 285. 


Dyspnoea, causes of, 24. 


dengue. 285. 




dothenenteria, 261. 


Embolism, cerebral, 259. 


enteric, 261. 


Emphysema, 60. 


etiological division of, 


Empyema, 89. 


261. 


Endocarditis, acute, 110. 


exanthematous, 291. 


chronic, 114. 


famine, 355. 


ulcerative, 113. 


forty-day, 261. 


Enteralgia, 199. 


fourteen days', 291. 


Enteric fever, 261. 


gastric. 261. 


Enteritis, catarrhal, 181. 


gastro-enteric, 261. 


Epigastric pulsation, causes of, 


heat, 255. 


Epilepsy, 245, 259. [19. 


hospital, 291. 


Erysipelas, 329. 


ileo-typhus, 261. 


Exanthematous fever, 291. 


jail, 201. 


Exophthalmic goitre, 147. 


malarial, 277. 


Expectoration, types of, 32. 


pernicious, 280. 




petechiel, 291. 


Falling sickness, 245. 


putrid, 291. 


Famine fever, 355. 


relapsing, 355. 


Fatty degeneration of heart, 


remittent, 296. 


141. 


scarlet, 306. 


liver, 215. 


ship, 291. 


Fever, abdominal typhus, 261 


simple intermittent, 377. 


acclimative, 296. 


southern, 296. 


African, 280, 296. 


spotted, 242. 


ardent, 280. 


sun, 255. 


autumnal, 261. 


thermic, 255. 


bilious, 296. 


tropical typhoid, 280. 


bilious remittent, 298 


typho-malarial, 287. 


break-bone, 285. 


typhoid, 261. 


camp, 291. 


typhoid affection, of 


cerebral-typhus, 291. 


Louis, 261. 


climatic, 280. 


typhus, 291. 


congestive, 280, 


western, 296. 


continued, 291, 296. 


yellow, 273. 



INDEX. 



451 



Fevers, tables of differential 
diagnosis of the five principal 
eruptive, 316. 

Flatulent colic, 200. 

Forty-day fever, 261. 

Fourteen days' fever, 291. 

Gall-stones, 219. 
Gangrenous sore-raouth, 155. 
Gastric catarrh, acute, 169. 

catarrh, chronic, ITl. 

fever, 261. 
Gastro-enteric fever, 261. 
Glossitis, 161. 
Glycosuria, 336. 
Gout, 343. 

flying, 332. 
Grand mal, 245. 
Grave's disease, 147. 

Hsematemesis, 27, 177. 

Hsemo-pericardium, 109. 

Hsgmoptysis, causes of, 27. 

Haut mal, 245. 

Headache, causes of, 23. 

Heart and pericardium, dis- 
eases of the, classified, 
14. 

dilatation of, 135. 
fatty degeneration of, 
141. 

hypertrophy of, 132. 

murmurs, classified, 131. 

sounds, 130. 
Heat apoplexy, 255. 

fever, 255. 
stroke, 255. 
Hepatic abscess, causes of 34. 



Hemiplegia, causes of, 29. 
Hemorrhage from the digestive 

tract, causes of, 

27, 

renal, 361. 
Hepatic colic, 219. 
Hooping cough, 58, 
Hospital fever, 291. 
Hydatids of the liver, 221. 
Hydrocephalus, acute, 238. 

chronic, 241. 
Hydro-nephrosis, 390. 
Hydro-pericardium, 108. 
Hydro-pneumo-thorax, 91. 
Hydro-thorax, 93. 
Hysteria, 259. 

Hio-typhus fever, 261. 
Infarction, pulmonary, 69. 
Infarctions, 324. 
Insolation, 255. 

Instantaneous death, causes of, 
31. 

Intermittent fever, simple, 277. 
Intestinal canal, diseases of the, 
classified, 12^ 
cohc, 199. 
hemorrhage, 194. 
obstruction, 195. 
Intestines, carcinoma of the, 
193. 

diseases of the, 181. 

Jail fever, 291. 
Jaundice, 213. 

black, 223. 

causes of, 25. 



452 



INDEX. 



Kidney, amyloid, 377, 

cirrhotic, 381. 

contracted, 381. 

diseases of the, classi- 
fied, 15. 

dropsy of the, 390. 

gin-drinkers', 381. 
'■ ' granular, 381. 

hob-nailed, 381. 

hyperaemia of the, 359. 

new growths of the, 
393. 

surgical, 396. 

Lardaceous liver, 218. 
Laryngeal phthisis, 40. 
Laryngitis, acute catarrhal, 37. 

acute croupous, 44. 

chronic catarrhal, 
40. 

iiarynx, diseases of the, 37. 

diseases of the, classi- 
fied, 13. 
Lead colic, 199. 
Liver, amyloid, 218. 

cancer of the, 216. 
cirrhosis of the. 210. 
diseases of the, 210. 
diseases of the, classified, 
12. 

fatty, 215. 

hydatids of the, 221. 

lardaceous, 218. 

yellow atrophy of the, 

223. 
waxy, 218. 
Lobar pneumonia, 76. 



Lobular pneumonia, 80. 
Locomotor ataxia, 251. 
Lungs, cancer of the, 74. 

diseases of the, classi- 
fied, 14. 

Malarial fevers, 277 
Marasmus, 183. 
Measles, 312. 
Meningitis, acute, 23^. 

basilar, 238. 
cerebro-spinal, 242. 
chronic, 236. 
pachy-, 236. 
simple, of the con- 
vexity, 232. 
subacute, 235. 
tubercular, 238. 
Milleturia, 336. 
Mitral obstruction, 121. 

regurgitation, 123. 
Morbus maculosus Werlhofir, 
341. 
sacer, 245. 
Mouth, catarrh of, 151. 

diseases of the, 151. 
gangrenous sore, 155. 
syphilitic affections of 

the, 15C. 
ulcers of the, 157. 
Myelitis, 249. 
Myocarditis, 139. 
Muguet, 154. 
Mumps, 159. 

Nephritis, parenchym a t o u s, 
367. 



INDEX. 



453 



Nervous cardiac palpitation, 
144. 

cardialgia, 175. 
system, diseases of 
the, classified, 9. 

Noma, 155. 
(Edema glottidis, 42. 
(Egyytian starstroke, 255. 
(Esophagus, dilatation of, 167. 

diseases of the, 166. 
diseases of the, 

classified, 11. 
nervous affections 

of, 169. 
perforation and 

rupture of, 168. 
stricture of the, 
166. 

Opium poisoning, 260. 
Organs of digestion, classified, 
10. 

of respiration, classi- 
fied, 18. 

the urinary, classified, 
15. 

Oxyuris vermicularis, 198. 

Pain in the thorax, causes of, 21. 
Paraplegia, causes of, 29. ^ 
Parenchymatous nephritis, 

acute, 367. 
Parotitis,- 159. 

Perforating duodenal ulcer, 186. 
Pericarditis, acute, 103. 

chronic, 107. 
Pericardium, cancer of the, 110. 

diseases of the, 
103. 



Pericardium, hsemo-, 109. 

hydro-, 108. 
pneumo-, 109. 
tuberculosis o f 
109. 

Peri-proctitis, 188. 

Peritonitis, 201. ^ 

acute primary, 201 . 
chronic, 208. 
infectious, 206. 

Perityphlitis, 186. 

Pernicious fever, 280. 

Pertussis, 58. 

Petechial fever, 291. 

Petit mal, 245. 

Pharyngeal croup, 164. 

Pharynx, diseases of the, 164. 

diseases of the, classi- 
fied, 10. 

Phthisis, 94. 

catarrhal, 94. 
fibrous, 94. 
laryngeal, 40. 
tubercular, 94. 
Physical signs of disease, 4. 
Pleura, diseases of the, classi- 
fied, 14. 
Pleurisy, 84. 

acute, 84. 
chronic, 89. 
sero-fibrous, 86. 
subacute, 86. 
Pneumonia, 76. 

brc nch')-, 80. 
catarrhal, 80. 
chronic catarrhal, 
94. 

croupou , 76, 



r 



454 



INDEX. 



Pneumou ia, fibrous, 82. 

interstitial, 82. 

lobar, 76. 

lobular, 80. 
Pneumo-pericardium, 109. 
Podagra, 343. 
Polvmorpha, 159. 
Polyuria, 338. 

Progressive muscular atrophy, 
254. 

Pseudo-membranous angina, 
345. 
croup, 
345. 

Ptyalism, 158. 
Pulmonary apoplexy, 69. 

cirrhosis, 82. 
congestion, 65. 
gangrene, 73. 
infarction, 69. 
oedema, 63. 
Pulmonic obstruction, 127. 

regurgitation, 127. 
stenosis, 127. 
valves, 127. 
Pulse, varieties of, 19. 
Purpura, 341. 

hemorrhagica, 341. 
Pus in urine, causes of, 31. 
Putrid fever, 291. 

sore throat, 345. 
Pyaemia, 326. 
Pyelitis, 385. 

Quinsy, 162. 

Rales, varieties of, 6. 
St. Guy's Dance, 397. 



Rational signs of disease, 3. 
Relapsing fever, 355. 
Remittent fever, 296. 
Renal calculi, 392. 
cancer, 394. 
congestion, 359. 
dilatation. 390. 
hemorrhage. 361. 
Respiration, organs of, classi- 
fied, 13. 
varieties of, 5. 
Retention of urine, causes of, 
30. 

Retro-pharyngeal abscess, 165. 
Rheumatism, 332. 

acute articular, 
332. 

chronic articular, 
334. 

muscular, 336. 

Rotheln. 315. 

Salivation, 158, 
Scarlet fever, 306. 
Scorbutus, 339. 
Scurvy, 339. 
Septicaemia, 324. 
Stomatitis, croupous, 152. 

diplitheretic, 153. 
*Sun fever, 255. 
Sun stroke, 25 5. 
Suppression of urine, causes of. 
30. 

Surgical kidney, 396. 
Syncope, 258, 
Ship fever, 291. 
Small-pox, 299. 
St. Vitus' Dance, 397. 



INDEX. 



455 



Soor, 154. 

Sore mouth, gangrenous, 155. 
throat, clergyman's, 40. 
putrid, 345. 
Southern fever, 296. 
Spinal cord, diseases within the 

classified, 9. 
Spotted fever, 342. 
Sprue, 154. 

Staristroke, segyptian, 255. 
Stomach, carcinoma of the, 173. 

chronic ulcer of the, 
179. 

diseases of, 169. 
diseases of the, classi- 
fied, 11. 
hemorrhage from the, 
177. 

Tabes dorsualis, 251. 

Table of differential diagnosis 

of the five principal eruptive 

fevers, 316. 
Taenia mcdiocanellata, 197. 

solium, 197. 
Thermic fever, 255. 
Thrombosis, cardiac, 143. 
Thrush, 154. 
Tonsillitis. 162. 
Trichocephalus dispar, 198, 
Tricuspid regurgitation, 128. 
Tropical typhoid fever, 280. 
Tubercular meningitis, 239. 
Tuberculosis, acute miliary, 94. 



Tuberculosis of the pL-iicur- 

dium, 109. 
Types of diarrhoea, 33. 

of expectoration, 32. 
TyphHtis, 183. 

Typhoid affection of Louis, 261. 

fever, 261. 
Typho-malarial fever, 287. 
Typhus fever, 291. 

Ulcerative endocarditis, 113. 
Ulcer of the stomach, chronic, 
179. 

Ulcers of the mouth, 157. 

Urgemia, 260, 362. 

Urinary organs, diseases of the, 

classified, 15. 
Valvular diseases of right heart, 
127. 

lesions, 116. 
Varieties of pulse, 19. 

of rales, 6. 

of respiration, 5. 
Variola, 299. 
Varioloid, 299. 
Vomiting, causes of, 22. 

Water-canker, 155. 
Waxy liver, 218. 
Western fever, 296. 
Whooping cough, 58. 
Worms, 197. 

Yellow (ever, 272. 

atrophy of liver, 238. 



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